The Social Determinants of Health in EMR: Working towards Regional and Country Policies

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The Social Determinants of Health in EMRWorking
towards Regional and Country Policies

• WHO Eastern Mediterranean Region
• Capacity Development Workshop on Health System
  Development
• Alexandria, Egypt
• 20-24 May 2007

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Why the social determinants of health?

• SDH emphasize the PHC approach
• Recent concern has been encouraged by the WHO
  Commission on the Social Determinants of Health.
• This presentation will identify priority SDH in
  the Region and relate the SDH and health equity
  agenda to regional and country policies, and to
  health systems.

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The Social Determinants of Health

• 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
• Krieger N. A glossary for social epidemiology. J
  Epidemiol Community
• Health 2001 55693-700

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The core problem

• Throughout the world, people who are
• vulnerable and socially disadvantaged have
• less access to health resources, get sicker, and
• die earlier than people in more privileged social
• positionsHealth gaps are growing.
• Irwin A. et al. The Commission on Social
  Determinants of Health
• Tackling the social roots of health inequities.
  PLoS Medicine 2006 3
• (6), e 106.

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Social determinants of high maternal mortality

• Proximal determinants
• Low level of mothers education
• Lack of decision making power among women
• Cultural norms which encourage women to downplay
  their health problems
• Poor quality health services
• Distal determinants
• Poverty
• Lack of national resources for health care
• Lack of concern for the status of women on the
  part of governing elites
• National and global failure to prioritize RH

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Health equity

• The absence of systematic disparities in health
  (or its determinants) between more and less
  advantaged social groups
• Certain differences are unfair and unjust
• WHO has declared that health is a human right
• Therefore health actions should be directed, at
  least in part, towards eliminating inequities in
  health

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Health Systems, Programs, Determinants
Interrelationships
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HEALTH SYSTEM CONCEPTUAL FRAMEWORK
Social Determinants of Health
GOALS OF HEALTH SYSTEM
SYSTEM BUILDING BLOCKS
Responsiveness
Information Support
Service provision
Governance leadership
Coverage
Health workforce
Quality, safety
Health
Efficiency
Medical products, technology
Provider performance
Financing
Financial protection
Equity
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WHO Commission on the Social Determinants of
Health (CSDH)

• Launched March 2005 to
• Identify and tackle persistent health inequities
  experienced by socially disadvantaged and
  marginalized populations
• Draw attention to the importance of the social
  causes of illhealth and to inequalities in health
  at the global, national and subnational levels
• Revisit Health for All and the Alma Ata
  Declaration, 1978, and Primary Health Care as a
  mechanism for providing universal health care

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CSDH activities include

• Knowledge Networks to synthesize the knowledge
  base for the various SDH and provide examples of
  best practice
• Working with civil society
• Country level work
• Preparation of a final report by the Commission

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Work of EMROIdentification of priority SDH
working towards a knowledge base

• Gender issues and womens enablement
• Improving access to health care for women
• Education/literacy for girls and women
• Employment and social protection
• Female genital mutilation as a gender and health
  issue in some countries of EMR
• Child labour and street children the causes
  originate in poverty and its corrosive effects on
  family life

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Priority SDH in EMR cont.

• Migrant workers concerns about health rights and
  limited access to health services
• Social exclusion
• Low status occupational groups
• The disabled
• Groups with a sexual orientation labeled as
  deviant
• Groups excluded on the basis of religion,
  ethnicity or language
• Those with stigmatized diseases or conditions
  the mentally ill, those with HIV/AIDS, TB, cancer
  etc.

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Priority SDH in EMR cont.

• Inequitable health systems as a barrier to health
  care
• Scarce resources or a low national priority for
  health
• National health policies that fail to prioritize
  health equity
• Maldistribution of facilities and/or funding
• Socially determined life styles and behaviors
  (the disadvantaged have fewer choices than the
  more advantaged)
• Smoking
• Nutrition related problems obesity and lack of
  adequate nutrition among the disadvantaged
• Traffic accidents

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Priority SDH in EMR cont.

• Conflicts and emergencies loss of human rights
  is the major underlying social determinant,
  involving
• Lack of security, living daily in fear
• Displacement from home and the familiar
• Loss of social networks and family structures
• Loss of livelihood daily activity, access to
  land, employment etc. resulting in extreme
  poverty
• Food insecurity due to lack of livelihood
• Lack of shelter, services etc. necessary to live
  in dignity
• Shelter a plastic sheet or the shade of a tree
• Lack of clean water and safe sanitation
• Lack of essential health and other services
• Lack of communications isolation

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Conflict Palestinian checkpoints

• Photo here

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For EMRO the following SDH policy areas have been
identified

• Developing a regional perspective on SDH, based
  on solid local evidence
• Identifying best practices to tackle SDH
• Improving health systems and financing to
  increase fairness
• Advocating for inclusion of SDH in all national
  policies and programs
• Implementing/facilitating interventions on the
  ground
• Expanding partnerships with stakeholders in the
  Region

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EMRO activities so farImproving the knowledge
base

• A regional discussion paper on SDH
• Papers on the knowledge base in Egypt, Iran,
  Jordan, Morocco, Oman, Pakistan and Palestine
• Publication of paper in The British Medical
  Journal
• Policy brief Tackling health inequities through
  action on the social determinants of health
• Paper on conflict and SDH in EMR, for CSDH

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Egypt the country study identified the following
SDH

• Child labor
• Poverty is the main cause of child labor
• 21 of children aged 6-14 work at some time
  during the year, most of them in rural areas
• 25 of working children had injuries at work
• 4 of the injured suffered long-term problems
• Gender issues Female-headed households
• 22 households were headed by females of whom
  83 were illiterate (compared to national figure
  of 50)
• Expenditure and income levels for these
  households were predominantly in the poorest two
  quintiles.

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Jordan the country study identified the
following SDH

• Gender and employment issues
• Women have had the right to vote and contest
  elections since 1974
• Womens participation in the formal labor force
  grew from 15 to 24 between 1980 and 2002. BUT
  average unemployment rates among women were 25,
  compared to 15 for men

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Islamic Republic of Iran current collaboration
between EMRO, WHO HQ, country office and MoHME

• Preparation of an updated, revised situation
• analysis of SDH in IRI, as a basis for future
• collaboration in the preparation of a strategic
• plan for tackling SDH and health equity.
• This collaboration supports work in IRI,
• identified by Geneva as a champion country
• in the Region for SDH and health equity.

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For country action, request from EMRO

• Support to
• Generate information on SD and the pathways
  through which they influence health
• Promote intersectoral collaboration, for example
  by establishing a formal body with responsibility
  to forward the SDH and health equity agenda
  across government sectors, with civil society and
  private partners
• Develop a national strategy for SDH

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For further information see

• Regional Observatory papers and data on SDH
• http//www.who.int/social_determinants/en/