WCSDH in Rio: Will the current reform enable the WHO to better address SDH?

Nicoletta Dentico talking on WHO reform and SDH

Live from Rio and recalling his experience in Manila, Renzo Guinto reflects on the unseen links between WHO reform and social determinants of health.

Last Tuesday, Cristobal, Pablo, Taavi, and I attended the stakeholder’s event organized by the People’s Health Movement (PHM). For more than a decade, PHM has been a leader in championing health as a fundamental human right and in pointing out the many defects in the current global health regime. The Movement finds its inspiration in the 1978 Alma Ata Declaration on Primary Health Care, which speaks of intersectoral cooperation, people’s participation, focus on prevention and promotion, and community development as vital approaches in achieving “health for all.”

Entitled “Protecting the Right to Health through an Action on Social Determinants,” the session looked into the different issues relating to social determinants of health such as power relations, the right to health, primary health care, and climate change. But one subtopic that caught my attention was the ongoing global debate on reforming the WHO and the future of global health governance.

This major issue has been rarely discussed in connection with social determinants of health. This is saddening, as WHO pushes for both reforming the organization and at the same time giving special attention on social determinants, but it failed to see the marriage between the two. And so, one of the speakers, Nicoletta Dentico from Italy, who is the coordinator of ‘Democratizing Global Health Coalition,’ during her presentation asked the question: Will the current reform enable the WHO to better address SDH?

I can’t avoid remembering my experience at the WHO meeting of the Western Pacific Regional Committee in Manila last week. On the first day of the meeting, Member States spent an entire afternoon discussing WHO reform without raising the aforementioned question, or any question that somehow implies this point. Even the Director General failed to bring SDH to the table. This has happened many times – WHO priorities are rarely seen under one huge umbrella, but are presented as disparate concerns and therefore are competing for political attention from Member States. I think this is one major area that WHO needs to reform: the ability to integrate the different issues that it tries to address, and to make explicit the links between them, for example WHO reform and SDH. Such framing of priorities will be helpful for Member States as they try to understand why these issues are raised and thus merit immediate action.

Going to the link between WHO reform and SDH, I believe the campaign for action on SDH will not move forward, within WHO and among Member States, if the principles that govern the SDH approach will not be explicitly adopted by WHO, for example as one of their “core businesses.” Nicoletta shared that in the original document on WHO reform, “Health and Development” was not actually identified as one of the core businesses of the future WHO. WHO’s reasoning behind this is that many other international organizations, such as UN agencies and health foundations, are already doing tremendous work in this area. However, this non-inclusion of development in the WHO reform agenda ignited opposition and criticism among some Member States. “Health and Development” was later added in the revised document.

I think WHO can do more than that, if it really aims to achieve substantial and genuine reform. Looking back at history, international health actually started as a charity work for religious groups and nongovernmental organizations, and later turned into a development issue, hence the participation of many new global health actors, even international development banks such as World Bank and Asian Development Bank. However, recent history and current global health data will clearly tell us that development alone is not sufficient anymore to improve health outcomes AND at the same time to reduce and even eliminate health inequalities within and between countries. Development can happen without justice and equity, and we have witnessed how many countries greatly improved their economies and communities with the help of development agencies while many segments of society are still left behind, totally forgotten by development. Development work even widened some gaps in health. Take for example the many development projects established in my country, the Philippines – despite existing development efforts, six of 10 Filipinos still die without seeing a doctor, and 150 out of 1000 mothers die of pregnancy-related deaths in the provinces, while the number is just one-tenth in urban cities.

In general, the situation is much better, but the inequalities remain.

Instead of development, WHO should enshrine “global health justice,” not just as one of its core businesses, but its CORE business. I can’t think of any other global health organization that has the capacity as well as the mandate to fulfill this role. This World Conference aims to put equity at the center of global health through action on social determinants of health, but we have a WHO that, despite its initiating a commission on SDH and now a conference, is ill-prepared to provide guidance and leadership in this area. The overall structure of WHO remains incompatible to global health justice work, as it continues to divide its work into disease silos and to align its priorities with available funding and not country needs. I remember even talking about SDH with WHO staff from other departments who are either unaware of the whole concept of SDH or even pessimistic about its full realization. I hope WHO will use this opportunity to see the connection of its desired internal reform with its equally desired vision of achieving global health equity, and align these two goals in the process.

Finally, I remember again the Director General scolding the Member States for not fully participating in the discussion on WHO reform. She said that Member States expect too much from the organization, but they contribute too little, especially in terms of assessed and voluntary contributions. Moreover, she called the attention of Member States who also sit in the boards of health foundations, for saying one thing during World Health Assemblies and for saying another thing during board meetings. She pointed out that WHO is divided into two – the Secretariat, whom she calls the “servants,” and the Member States, the “bosses,” and so she asked the plenary to “tell me the priorities.”

Dr. Margaret Chan at the WPRO Meeting: "You Member States are the owners of WHO. We the Secretariat are your servants."

I agree that Member States have to be more assertive this time – and so we in civil society should not forget targeting our advocacy work towards governments, because they are the ones who make the decisions in Geneva every May and who implement (or not implement) them back home. If WHO has to be reformed, Member States should begin taking ownership of WHO.

However, and since the Director General pointed out the dual nature of WHO, the Secretariat cannot totally point fingers to Member States for the responsibility of global health leadership. I believe the Secretariat exists to serve as the guiding light of all Member States, and during times when Member States are confused or indecisive, the Secretariat should be providing not just the technical assistance but also the moral impetus for decision and action. WHO should make use of this role in pushing action on social determinants, and ultimately the achievement of global health justice. I think this is one of the reasons why  the vision of Alma Ata somehow failed, when WHO reverted back to its disease-oriented programs and forgot about the horizontal, multisectoral approaches they advocated for in the Declaration, sending the wrong signal to Member States and other global health players.

In conclusion, to answer the question, it is clear that the ongoing debate on WHO reform has not touched social determinants, or SDH has not touched WHO reform yet. I hope that after the World Conference, especially during the Special Executive Board Meeting on WHO reform that will happen on the last week of October in Geneva, this critical question will be asked.

Renzo Guinto

WCSDH in Rio: Country Case Studies on SDH

One of the members of our delegation, Taavi Tillmann from the United Kingdom, who is also a member of the Small Working Group on Health Inequities, talks about the 28 case studies published online by WHO in commemoration of the World Conference on Social Determinants of Health.

In preparation for the World Conference on the Social Determinants of Health, 26 countries were asked to write short reports about how they have been changing social determinants of health (SDH) in the past. These reports showed an immense diversity in form, highlighting that the boundaries of SDH are very blurry and there is still confusion about what SDH really means for policymakers. Some also appeared to be written in a rush (with spelling mistakes throughout) highlighting that SDH is still largely ignored by many countries. Notably, there are no reports from any European nation.

To save you the 8 hours it took me to read them, I have condensed the key take home examples below.

1. South Australia appears to be the global leader in incorporating “Health in All Policies” approachinto the entire government. This is somewhat similar to Scandinavian effort, and will compare these two at another point. Nonetheless, the Australian key timeline was:
   • For decades, public health academics interested in health inequalities in Australia had been not only gathering and publishing their data, but working hard to make their conclusions accessible to the public and policymakers. “Policy makers and public health practitioners need simple, precise, easy-to-understand, easy-to-learn, visualize-able information at their constituents’ level.” (Many a global health project comes to my mind which was academically brilliant, but the team was unable to communicate it at constituents’ levels.) Accordingly, the Australians have been publishing “Social Health Atlases” to illustrate and monitor inequalities. This caused health inequality to decrease between 1987-1997. However, between 1997-2007, inequality stagnated.
   • In 2007, the government recruited an external public health expert, Professor Ilona Kickbusch, for a 3-month job where she had to come up with a new health strategy. Her report was essentially a “Health in All Policies” approach.
   • The government approved this approach at the highest level, and all government sectors were publically and formally asked to participate. i.e. there was strong political will to improve health with a long-term perspective, in a cheaper way. This will was largely achieved by economic arguments that said: “if you don’t do “Health in All” (red line), then the alternative is state bankruptcy (blue line)”.

1. • Note how the government decided to invest now, and hope for returns 25 years later. I applaud this long-term view, and we should ask other governments to do the same
   • Subsequently, various projects were set up between different government departments to improve SDH that also meet other policy targets. E.g.: an inter-ministerial project to improve mobile broadband access that enables the public to also access health information; an inter-ministerial project to increase use of public transport by 10%; or decrease obesity by 10%; or get more aboriginal people to get a drivers’ license, and therefore reduce RTAs etc. Accountability is strong throughout, so if a project fails, all the participating ministries will be punished.
   • A key side benefit is that it got many policymakers to start thinking about their work through the health lens, thus setting the scene for future, braver SDH changes.

In all, Australia is years if not decades ahead of other countries in integrating the SDH or “Health in all policies” approach throughout its government. This pioneering case maps out how healthy governments could be replicated by other countries.

2. Malaysia’s government got set on reducing inequalities already 50 years ago, back when they inherited a vastly unequal society. They set out to reduce inequalities by giving extra support to the weaker ethnic, rural communities. They were very successful, as seen by increased equality of poverty and health:

However, progress has stagnated since 2000. This is due largely to the East Asian Financial crisis (that the IMF aggravated).

3. Costa Rica did extremely well in raising health with little money (red line), and its life expectancy is now a staggering 80.

The main cause of this success was huge increases in public spending, with a quarter of the county’s GDP being devoted to public social spending. This is in stark contrast to those advocating for strong austerity measures in Greece, UK or other countries whose GDP per capita is already many times that of Costa Rica’s.

4. Brazil gave two interesting case studies: 1) over the past decades, they have been giving cash benefits to very poor families with certain conditionalities: all children must attend 85% of school; no child is allowed to work; and mothers must attend perinatal programmes. Interestingly, the cash was given to the wife of the house. Results show prevention of malnutrition with concurrent improvements in education (as a key social determinants of future health) and improved gender inequality.

2) Brazil‘s second case was a small but beautiful illustration of how to elevate people into communities. A slum area called Morro da Policia was riddled with litter, rats and drug dealers, and the people had no future. A bunch of activists from PHM came in, cleaned up some of the litter and got everyone in the community, including drug dealers, to get excited about making some real changes. They planted gardens and dug water pipes, but the real change was in the faces of the people, who for the first time felt proud to belong to an inclusive, progressive community. A video shows a drug dealer at the end of the programme passionately talking about the benefits of community collaboration. Never before have I seen a drug dealer so positively transformed by anything.

5. Iran gave a completely different story. In Iran, Road Traffic accidents (RTAs) are the single biggest loss of DALYs owing to a bad driving culture. They turned this around not with mass-advertisement, or getting those in power to punish bad drivers. It was done by children. Their programme enlisted 8 million schoolkids to become “Little police officers”. Each child was thoroughly educated about the 8 key aspects of bad driving (Speeding; dangerous overtaking maneuvers; using mobiles whilst driving; chatting away while driving; eating while driving; driving while fatigued; not fastening seat belts; not attending to traffic signs and signals). Kids were issued with various booklets about the topic, as well as little pretend “arrest notepads” as well as other police paraphernalia. They then went about reprimanding their parents and others to improve their driving skills. 85% of parents responded positively to their kids’ notices, leading to a 20% reduction in accidents (about 200 000 accidents) and 10% reduction in road-deaths (about 5 000 lives saved). This is an astonishing feat, given that it was school-age kids who told off their parent governors. Just imagine what medically-educated university students could achieve if we tell off our adult governments. On a personal note, the example resonated a personal note with my childhood. When I was 6, I was convinced that I wanted to become a policeman. I made my own police-belt, complete with arrest-notebook, and went about issuing penalty notices to family for offences like leaving the toilet seat up. Kids have a huge potential resource in that they love to role-play. Tapping into this resource can unleash a wealth of energy, which can be channeled to change unhealthy social norms.

The other countries presented a varied mix of ideas. The Solomon Islands, Kiribati, Vietnam are documenting evidence on domestic violence, in an attempt to address gender inequality as a SDH. In India, an umbrella called “Voluntary Health Association of India” is starting to link together the 4000 health related NGOs that operate in India, in hope of identifying common policy goals to campaign on as a joint civil society initiative. This is similar to what avaaz.org was doing in the UK. Creating short-term unity on one political ask is an indispensable tool in the advocacy toolbelt, so we welcome this promising step by India. In a similar tone, the new government of Egypt spoke passionately about how it was mass social participation in civil society that brought the revolution this sprint, and how social participation in civil society must continue for SDH to be changed.

Chile gave a lengthy account of how it has measured and planned SDH action. Prior to the right wing government taking over two years ago, it had a whole government department dedicated to the topic. The new government dismantled the programme in their first day in office, so the document can be seen as an obituary.  My Chilean colleague, Cristobal, today enlightened me about how Chilean students are still protesting for 6 months to achieve high quality and free education for all. They are even taking their case to the European Parliament, OECD, and UNESCO. This makes me embarrassed at the feeble attempts by UK students against university top-up fees.

Many countries focused on mainstream public health issues, rather than SDH. For example, Jordan spoke about taking initial steps in improving food labeling to prevent obesity, Namibia spoke about how to control a polio epidemic, and Kenya spoke about success in deworming children, and Pakistan spoke about how to give the poor access to healthcare. It seemed these countries had either no active work on SDH, or they were just very pleased with their public health work.

To summarize, various policymakers across the world currently have an incredibly wide, rich diversity in understanding what SDH is, and wide array of experience in what works and what fails, as they take their first, baby steps. The conference will no doubt prove as a useful swap shop for ideas that can then cross-fertilize each other. However, many policymakers are still crawling around in the dark, oblivious to the notion that the SDH will be on the mainstream agenda for the future, and it is in their self-interest to get on the agenda before their competitors do. It is our job, as beacons of medical knowledge, as well as protectors of those in sickness and need, to keep learning and spreading as much as we can about the SDH, so to accelerate this transformation. Thank you for reading this far.

Taavi Tillmann

IFMSA dancing “samba” for health equity in Rio – and everywhere!

Good day IFMSA family!

I write to you today from Rio de Janeiro, in behalf of the 11-member IFMSA delegation to the WHO World Conference on Social Determinants of Health. For the next three days, more than 1000 leaders from around the world, representing Member States, civil society, intergovernmental organizations, and academia, will be convening to exchange ideas and experiences on how to advance the global movement for health equity through action on social determinants of health. “All for equity,” the conference theme says, and our participation in the WCSDH is our way of saying “IFMSA is for equity too!”

But we also want to ensure that ALL of IFMSA is for equity, as we envision a new generation of doctors who will champion health equity in all places and at all times. That is why our Federation designated the week of October 17-23, 2011 as the IFMSA Week of Global Action on Social Determinants of Health. We want to send a signal to the leaders in Rio that we medical students support action on social determinants, and we want to start doing the action now.

Thus, we invite you to keep track of updates and reflections from our delegates in the IFMSA wordpress (ifmsa.wordpress.com) and in the Root Out, Reach Out website (root-out.org). The campaign website also contains useful resources on SDH, the World Conference, and the Week of Global Action. Also, we ask you to help spread this SDH-virus that has been lingering in IFMSA for the past few months. Share our website as well as our Facebook page in your Facebook account, and follow our tweets on SDH and WCSDH in the IFMSA and Root Out, Reach Out Twitter accounts.

Finally, at this juncture, it is also fitting to recognize the outstanding work of the Small Working Group (SWG) on Health Inequities, which in the previous months has laid down the groundwork for a global campaign on health equity within our Federation. The work of the SWG is the reason why some of your National Member Organizations (NMOs) will be holding educational fora and multi-stakeholder discussions this week in your respective countries. We hope that we as a Federation will sustain this global movement even beyond the WCSDH. This will only happen if all of us will join in this global “samba” for health!

Let’s all “samba” for health equity, in Rio and in the world entire!

In behalf of the IFMSA delegation to the WCSDH,

Renzo Guinto

Facilitator, SWG on Health Inequities

Over-all Coordinator, Root Out, Reach Out Campaign

Regional Coordinator for the Asia-Pacific

International Federation of Medical Students’ Associations