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)”.


    • 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

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