After Rio, where to?

The IFMSA delegation at the World Conference on Social Determinants of Health

In this commentary, Renzo Guinto analyzes the aftermath of the World Conference on Social Determinants of Health held last October 19-21, 2011 in Rio de Janeiro, Brazil, and reminds all stakeholders, including IFMSA, that we cannot fail the second time around. More articles about “Youth and the Social Determinants of Health” in Medical Students International 25http://issuu.com/ifmsa/docs/msi25_onlinedistribution/1

 

Ramon Lorenzo Luis R. Guinto

The road, or rather the flight to Rio de Janeiro, Brazil is the longest I ever took. Two days to the destination, two days on the way back, but at the end of the nine-day sojourn, I can say it was all worth it. As someone who lives in Asia, you only get to South America once in a blue moon. I feel blessed because this trip was not just my first to the continent, but the main object was historic and inspirational.

For three days, more than a thousand public health experts coming from governments, UN agencies, academia, and civil society gathered at the World Conference on Social Determinants of Health to discuss how global health equity can be achieved. Unfortunately, the road towards it is not as smooth as my flight to the land of samba.

To illustrate the gravity of the situation, I turned to my reference materials. In Southeast Asia alone, glaring inequalities in maternal mortality rates can be noted: 339 out of 100,000 mothers in Laos, 229 in Indonesia, 84 in the Philippines, and only 16 in Singapore (1). On the other hand, when referring to inequities within countries, the classic example in social determinants literature is that of Glasgow in Scotland. Despite it being a city in a rich industrialized country, there exists a 30-year gap in life expectancy between the city’s most and least advantaged communities (2).

Clearly, there are forces that shape these inequities, and biomedicine realized that genetic and other individual factors have little to do with these gross inequalities at the population level. Two hundred years ago, the German physician Rudolf Virchow (3), who is regarded as the Father of Social Medicine, had already hit the nail at the head when he asked: “Do we not always find the diseases of the populace traceable to defects in society?”

It is therefore with this background that the World Conference was organized, with the intent of engaging “high level political support to make progress on national policies to address social determinants of health to reduce health inequities” (4). Moreover, the conference is an off-shoot of the 2008 report of the World Health Organization (WHO) Commission on Social Determinants of Health (5), which synthesized evidence from around the world illustrating how social determinants of health (SDH) – the conditions in which people are born, grow, live, work and age – bring about avoidable health inequities within and between countries.

The Commission, headed by renowned British social epidemiologist Professor Sir Michael Marmot, also listed down proposals for action on social determinants, which were summarized into three overarching recommendations: 1) the improvement of daily living conditions; 2) tackling the inequitable distribution of money, power, and resources; and 3) measuring and understanding the problem and assessing the impact of action.

Mixed views

The overall outcome of the conference itself can be described as equivocal, as it has drawn mixed views from different sectors. Some saw the conference as a major step towards renewing the global health equity debate, even being tagged as the new “Alma Ata,” in reference to the landmark 1978 Alma Ata Declaration on Primary Health Care (6). Although not explicitly using the phrase “social determinants of health,” the Declaration was the first international document that recognized gross health inequities as “politically, socially, and economically unacceptable” and which had called for intersectoral action and international collaboration towards the achievement of “health for all by the year 2000.”

However, others noted the diminished ambition of this event, especially of its main product – the Rio Political Declaration on Social Determinants of Health (7). This new document laid out commitments and recommendations from the over 100 governments present, capturing the five themes of the conference – governance, participation, the role of the health sector, alignment of global priorities, and monitoring of progress (8). However, other groups, especially civil society, criticized the document as being silent about some fundamental and crucial subjects such as trade as a social determinant of health, the links between social determinants of health, climate change, and sustainable development, and ultimately the redistribution of power, money, and resources, which has been the clarion call of the Commission’s Report since its publication.

Despite the document stepping on middle ground, there are still reasons to celebrate. The World Conference provided a venue for academics and civil society to gather and combine their voices for the revival of the health equity debate. In recent years, especially since the failure of Alma Ata in 2000, international networks such as the People’s Health Movement (9) have created their own platforms for global discussion on health equity and social justice, but none of these are either initiated or actively participated in by the WHO or any other intergovernmental agency.

The Rio conference, on the other hand, was the brainchild of WHO as requested by Member States through a World Health Assembly resolution in 2008 (10). Thus, this event served as an opportunity for meaningful dialogue between governments and UN agencies on one hand and civil society and academia on the other. Civil society groups were even allowed to organize their own side events, which further contributed to the solidifying of existing international and regional networks.

The People’s Health Movement (PHM) in particular also made use of this rare chance to concretize their dismay towards the Rio Political Declaration. Considered as the largest network of health activists calling for the revival of Alma Ata principles and of the vision of “health for all,” PHM came up with its own “Alternative Rio Declaration” (11). In this document, PHM listed down specific and concrete measures to address global health inequities such as the use of progressive taxation, reducing the clout of financial capital, use of health impact assessments in trade agreements, reconceptualization of development aid as an international obligation, and democratization of global governance, to name a few. The group’s statement somehow reflects the dissatisfaction towards the status quo, embodied by the ongoing Occupy protests which have spread from Wall Street to across the globe (12).

PHM and civil society at large even infiltrated the closing panel of the conference in a grand manner. One of its members, Dr. David Sanders from the University of Western Cape in South Africa, lambasted the Rio Declaration’s silence on unfair trade in food production and the “brain robbery” of health workers by Northern countries. Such fearless statements triggered the only standing ovation during the three-day conference.

Speaking the SDH Language

Another positive sign that we have observed during the conference is that some governments are now starting to speak the language of social determinants. Before the World Conference, I have previously attended a few meetings on social determinants. It is evident that despite the publication of the Commission’s Report and the wide availability of resources on social determinants, there remains diversity in understanding of the concept, ranging from promoting healthy lifestyle among local politicians (hoping that their good health will translate into good policies) to addressing global determinants such as climate change and the financial crisis.

In Rio, it seemed that some countries have already grasped the idea, while a few were actually fairly advanced in their understanding and implementation of action on social determinants. For example, South Australia boasts its “Health in all Policies” approach which enables other departments beyond the health sector to apply a “health lens analysis” to their policies and projects (13). Thailand instituted a National Health Assembly in an attempt to democratize health governance and allow participation from all sectors in priority setting and decision making (14). Finland even went on by declaring the welfare state as the best medicine against growing health inequities (15).

Despite this, albeit minor, victory, it is important to keep in mind that no matter what ministers of health declare in international conferences like this, most of the crucial decisions governing social determinants of health are under the jurisdiction of other domestic leaders such as ministers of finance or labor or even the prime ministers and presidents themselves, none of whom are present in the conference (16). The same can be said of the international arena – key actors such as the United Nations, World Bank, and World Trade Organization were also absent in Rio. Expressing a commitment during the World Conference is just half the battle – advocating for action to other sectors at home still remains the major formidable task.

Consistency is key

Even after the World Conference, health equity activists should also keep an eye at the World Health Organization. Observers of global health history clearly understand WHO’s tendency to switch themes from time to time, depending on the tune of some donor countries, influential NGOs and academic think tanks, and even private donors.  If WHO is really serious about “closing the gap in our generation” as the Commission’s Report’s title says, then the organization should remain consistent in its policy pronouncements from the Director-General to its country offices, and the SDH framework should be reflected in all its implemented programs, whether on HIV-AIDS to NCDs.

It is saddening that “social determinants” or “health equity” is not mentioned in the candidature current WHO Director-General Dr. Margaret Chan, who is now seeking another five-year term (17). Surely, as the only candidate for the post, she will be given another chance to lead WHO and to push forward the health equity agenda. Not only will it complement her agenda towards stronger health systems and a reformed WHO, this work on social determinants, and not her present focus on NCDs or any other vertical disease-oriented program, could also become her enduring legacy to global health.

Finally, again speaking of consistency, governments should start realizing – and realizing through the hard way – that business as usual is not an option for our global health future.

Health equity at the heart of IFMSA

Finally, this commentary will not end without looking at the role of the International Federation of Medical Students’ Associations (IFMSA) in this ongoing global debate. In 2011, IFMSA made health equity and social determinants of health a key policy focus (16), commencing with the passing of a policy statement on the matter in Jakarta (18). For months, the Small Working Group on Health Inequities under the Standing Committee on Public Health energized the discussions, both online and in actual meetings and consultations, which then culminated in a magnetic presence in all standing committee and regional sessions, and an overwhelmingly-attended forum with Sir Michael Marmot during our 60th anniversary conference. During that week, “SDH” became the mantra of Copenhagen.

Now, after Rio comes Accra, Ghana, which hosts IFMSA’s March Meeting this 2012, revolving around the theme of social determinants of health. This assembly is accompanied with a pre-General Assembly workshop on SDH and a presentation to the plenary on the proposed Global Health Equity Initiative. All these, I believe, will set the tone for IFMSA’s future.

This “SDH” capital that has been amassed in 2011 should not be put to waste, and I hope the future generations of IFMSA leaders and members will not cease talking about it and doing something about it. I recall someone telling me, “There should be no SDH-related activity in future meetings after Ghana.” I beg to disagree – the discussions should continue beyond Accra – as we already triumphantly did from Jakarta to Copenhagen to Rio.

We should remember that for every missed opportunity to discuss and to act on this crucial issue of our times, someone has to pay the price. Global health equity is not merely a theme for a conference, but a real global challenge that a truly global and truly health-committed organization should tackle in the 21st century.

Our aim is to create a global movement, not to make it a topic for a session. Every General Assembly has a new breed emerging, and therefore every General Assembly should not stop sowing the seeds of health equity into each IFMSA generation.

Medical students as social determinants of health

Looking at particular social determinants, I hope to see IFMSA spark a discussion about the management of human resources for health, including medical students who will soon become physicians, as an important global social determinant of health (19). I already mentioned about the “brain robbery” of health workers by developed countries from developing countries being a hot topic in Rio. It cannot be denied that medical students and young doctors play a vital part in this ongoing process.

As an international federation of medical students, it is our obligation to look into this issue, not just in medical education, which is only one segment of the whole health human resource production process, but also in the recruitment, certification, deployment, quality assurance, and compensation of physicians and health workers. These processes, in turn, are inextricably intertwined with issues concerning global trade, human migration, and global health governance, to name a few.

For example, a closer look into our professional exchange programs would enable us to understand if such programs actually promote global health learning for meeting local needs, or instead lead to global health inequalities by encouraging young physicians to move from their places of origin and training to new locations, which are often more lucrative but where they are needed least. I am sure many of our members will feel uncomfortable about this matter, but if we truly want to close the health gap, this one cannot be ignored.

Time to Become Revolutionary Doctors

Sometimes, no matter how well-informed, updated, and passionate I am about the issue of social determinants and health equity, I feel that I still do not have the exact answers. But also I think what is important now is that we medical students have already started talking about it – that we condemn the inequalities in health, that we understand the root causes of ill health and health inequities, and that we seek for ways to change the status quo. The members of the IFMSA delegation even expressed this desire and optimism in a statement distributed during the final day of the World Conference:

“We medical students commit ourselves to continue engaging with all sectors involved in the work towards global health equity, spreading awareness of the social dimensions of health to our fellow young people, mobilizing them to take action in their respective communities and countries, doing our part, little by little, but with courage, constancy, and conviction.” (20)

We therefore invite every member of this Federation to embrace this commitment, now as medical students, and beyond, when we become doctors of the future, until we see the day when, in the words of former UN secretary-general Kofi Anan, “health will finally be seen not as a blessing to be wished for, but as a human right to be fought for.”

This year and beyond, we, IFMSA, must keep reminding the global health world that we, medical students and young people at large, are not mere observers or beneficiaries, but are key players in this global movement. We will inherit this current global health regime sooner rather than later, and so we must exhaust all the platforms within our reach not tomorrow but now.

So, after Rio, where to? For IFMSA and medical students worldwide, it is time to, quoting from a new book entitled Revolutionary Doctors, “combine the humanitarian mission of medicine with the creation of a just society” (21). Realizing this requires an unwavering commitment to social determinants and “health for all.”

About the Author

A final year medical student at the University of the Philippines Manila, Ramon Lorenzo Luis R. Guinto (Renzo) is the facilitator of the SCOPH Small Working Group on Health Inequities and head of the IFMSA delegation in the World Conference on Social Determinants of Health. He is also the Regional Coordinator for the Asia-Pacific of IFMSA and immediate past president of the Asian Medical Students’ Association-Philippines, the IFMSA NMO in the Philippines.

 

 

References

  1. Chongsuvivatwong V, et al.  Health and health-care systems in Southeast Asia: diversity and transitions. Lancet 2011; 377: 429–37. Available from: doi:10.1016/S0140-6736(10)61507-3.
  2. Hanlon P, Walsh D & Whyte B. Let Glasgow flourish. Glasgow: Glasgow Centre for Population Health, 2006.
  3. Virchow R. Collected Essays on Public Health and Epidemiology. Cambridge: Science History Publications; 1848/1985.
  4. World Health Organization Department of Ethics, Equity, Trade, and Human Rights. Concept Paper for the World Conference on Social Determinants of Health [Online]. Geneva: World Health Organization, 2010. Available from: http://www.who.int/social_determinants/draft_concept_paper_september_2010.pdf. [Accessed 10th January 2012].
  5. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: World Health Organization, 2008.
  6. WHO, UNICEF. Declaration of Alma-Ata. Alma-Ata, USSR, 1978. Available from: http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf.  [Accessed 26th October 2011].
  7. World Health Organization. Rio Political Declaration on Social Determinants of Health. Rio de Janeiro, Brazil, 2011. Available from: http://www.who.int/sdhconference/declaration/Rio_political_declaration.pdf.  [Accessed 21st October 2011].
  8. Closing the gap: policy into practice on social determinants of health: discussion paper for the World Conference on Social Determinants of Health. Geneva: World Health Organization, 2008.
  9. People’s Health Movement. Available from: phmovement.org [Accessed 10th January 2012].
  10. Resolution WHA 62.14. Reducing health inequities through action on the social determinants of health. Geneva: World Health Organization, 2009. Available from: http://apps.who.int/gb/ebwha/pdf_files/A62/A62_R14-en.pdf.  [Accessed 26th September 2011].
  11. Protecting the right to health through action on the social determinants of health: a declaration by public interest civil society organizations and social movements. Rio de Janeiro, Brazil, 2011. Available from: http://www.phmovement.org/sites/www.phmovement.org/files/AlternativeCivilSocietyDeclaration20Sep.pdf.  [Accessed 29th October 2011].
  12. Occupy Wall Street. Available from: http://occupywallst.org/. [Accessed 10th January 2012].
  13. Kickbusch I. Health in all policies: The evolution of the concept of horizontal health governance. In: Kickbusch I, Buckett K. (eds.) Implementing Health in All Policies: Adelaide 2010. Adelaide: Department of Health, Government of South Australia, 2010: pp. 11-23.
  14. Rasanathan, K, Posayanonda, T, Birmingham, M. and Tangcharoensathien, V. Innovation and participation for healthy public policy: the first National Health Assembly in Thailand. Health Expectations, February 1, 2011. Available from: doi: 10.1111/j.1369-7625.2010.00656.x
  15. Ministry of Social Affairs and Health, Finland. Minister Guzenina-Richardson: The welfare state is the best medicine against growing health inequalities. [Online]. Available from:  www.stm.fi/tiedotteet/tiedote/view/1569646#en.  [Accessed 3rd December 2011].
  16. Guinto, R, et al. Students’ perspective on rooting out causes of health injustice. [Online] Lancet, October 20, 2011. Available from: doi:10.1016/S0140-6736(11)61628-0. [Accessed 20th October 2011].
  17. Chan, M. Dr. Chan’s vision on WHO priorities and strategies [Online]. Geneva: World Health Organization, 2011. Available from: http://www.who.int/mediacentre/events/governance/dgelection/2012/CV_Chan_2011.pdf. [Accessed 25th December 2011].
  18. International Federation of Medical Students’ Associations. Policy statement on health inequity and the social determinants of health. Jakarta, Indonesia, 60th March General Assembly of the International Federation of Medical Students’ Associations. March, 2011. Available from: http://www.ifmsa.org [Accessed 26th September 2011].
  19. Globalization and Health Knowledge Network. Towards health-equitable globalisation: rights, regulation and redistribution. Final report of the Globalisation Knowledge Network of the Commission on Social Determinants of Health. Geneva: World Health Organization, 2007.
  20. International Federation of Medical Students’ Associations. Medical Students’ Perspective on the Rio Declaration. October 21, 2011. Available from: ifmsa.wordpress.com [Accessed 21st October 2011].
  21. Brouwer, S. Revolutionary Doctors: How Venezuela and Cuba are changing the world’s conception of health care. New York: Monthly Press Review, 2011.

WCSDH in Rio: Chile: Steps forward and backward equity

Live from Rio, Cristobal Cuadrado, former president of IFMSA-Chile and member of the IFMSA Delegation to the WHO World Conference on Social Determinants of Health, writes about the Chilean experience in fighting health inequities and acting on social determinants of health. This October, IFMSA-Chile, with Cristobal as general coordinator, organized the First Congress on Health and Poverty in Santiago. The conference was graced by Professor Sir Michael Marmot, head of the 2008 WHO Commission on Social Determinants of Health.

In the context of the World Conference on Social Determinants of Health at Rio de Janeiro, we are having a wide discussion about evidence and experiences of different countries into this field. This entry talks about the Chilean situation on Health Equity from the perspective of the Social Determinants of Health. Dr. Jeannete Vega, past Health Minister Deputy of Chile during the government of Michelle Bachelet, had summit a draft paper (nº25) entitled “Steps towards the health equity agenda in Chile”, this represent a summary and reflection of this paper.

Generalities about Chile and its Health System.

US$ 14,300 in 2010; the minimum wage rose to US$ 350 in 2010 and the current inflation and unemployment rates are 1.4% and 8.6% respectively. Chile scores high in several health indicators, such as life expectancy at birth (81.2 years for women and years for men), infant mortality (8.3 per 1000 live births). The Health System in Chile it is decentralized with 29 local Public Health Services that serve approximately 75 % of the population. The other 25% of the population is covered by a private insurance and provision scheme administered by a number of private insurance institutions (ISAPRE) that provide mainly curative services mostly to those with the highest income, and of younger ages.

As a little history, the actual shape of the Chilean health system is related with the undertaken by the Pinochet military government following the coup d’état in 1973, establishing competition between public and private health insurers and promoted private health services, following neoliberal principles. These principles have changed very little since the early 90ths were the democracy had come again to our country.

The employee mandatory contribution accounts for 7% of the salaries and goes to either the public insurance (FONASA) or the private insurance companies. The National Health Fund (FONASA, Fondo Nacional de Salud) manages public health insurance. All citizens in Chile are insured by Fonasa unless they choose to contribute to a private insurer (ISAPRE). Individuals covered by FONASA may receive health services from either public facilities or a preferred private provider. The Ministry of Health manages vertical programs, public health interventions, and the health care personnel from public facilities. The focus on Primary Heath is location of the health centers and the income level of the municipality, where a health center located in historical context leading to action on Social Determinants and Health Equity

Timeline on Health&Equity issues during the past 20 years

1990-2000

Two streams of social policies were developed during the 1990’s. Firstly, sectoral policies, such as education, health and housing, centered on guaranteeing an adequate level of services and benefits for all the population in an equal opportunity perspective. Secondly, specific programs directed towards disadvantaged vulnerable groups to ensure access to the opportunities available through the sectoral policies, economic growth and development in general.

2000 -2010

Between 2000 and 2006 the emphasis was put in introducing programs to improve structural social determinants: improving neighborhoods conditions (Chile Barrio), diminishing extreme poverty (Chile Solidario) and others. All these programs had in common a policy and programmatic approach centered on the perceived needs of the person, in a family and in a community, rather than on the supply based normative needs, with services built around them on an integrated (intersectoral) manner.  The landmark social program of the last government of this period is Chile Crece Contigo, a program with deep roots on the perspective of SDH, so we will go a little bit further on this experience.

 

Chile Crece Contigo (Chile Growth with you): an intersectoral approach to tackle inequities from the beginning.

The central principle on this program is “Equity from the beginning”. Chile Crece Contigo initiative for action included the Rights of Children and the State’s responsibility to ensure them as a universal principle, creating a integrated system based on rights during the life course. The Ministries of Planning and Finances leveraged funding to investigate policy alternatives, systematize and evaluate innovative local projects and develop possible interventions, including pilot experiences. The evidence base of effective interventions, that the Ministry of Planning and other sectors were building, also looked at international experience

After a long work, in October 2006 President Bachelet announced the creation of the integrated and integral social protection system for early child development, called Chile Crece Contigo. Its social equity goal was ambitious and aimed to eliminate socioeconomic differences in achieving maximum development potential across the social gradient.

The system would accompany children and their families from gestation until they entered the school system in pre-kinder, age 4 years. Chile Crece Contigo would provide all boys and girls access to universal benefits and services to take care of their necessities and support their development in each stage of the life cycle, during early childhood. Additionally, it would contribute to induce basic conditions in the psycho-emotional and physical environment in order to favor harmonious and integral development, in accordance with the evolution of their life course. During 2007 new programs were introduced that required integrated action by two or more sectors: Support for Biopsychosocial Development (Ministry of Health, Ministry of Development, the Fund for initiatives to support local child development initiatives (Ministry of Planning– municipalities) and Fund for Childhood Initiatives (Ministry of Planning – public, private and community agents).

Chile Crece Contigo offers different levels of support and guaranties for all boys, girls and their families. To each according to his/her specific needs.

  1. Strengthened legislation and standards of protection for maternity and paternity for all population.
  2. Free Nursery and Preschool access for the 60% of more vulnerable families
  3. Improved quality in prenatal care.
  4. Humanized birth (with participation of the father)
  5. Improved well child care, especially for the first 2 years (Biopsychosocial support)
  6. Strengthened access to health care for all boys and girls from the first prenatal control until entry into the school system
  7. Increased support and guarantees for boys and girls from the 60% of homes with lesser income or in special situations of vulnerability.

The process of implementation of Chile Crece Contigo to date includes the action in all the Municipalities within the Country through generation of the local intersectoral networks in charge. Since 2007:

  • More than 649.132 pregnant women have enter the program
  • Almost 75% of eligible births (non-emergency) have occurred with the presence of the father since 2009.
  • More than 90.000 visits to the households of pregnant women with social risk.
  • More than 1.000.000 educational sessions to promote early child development (ECD) with families of children at risk.
  • More than 270.000 visits to the household of families with children at risk in their development.
  • Since September 2009, every child born in Chile receives a set of basic implements for initial child care including a cradle, a baby carrier, massage oil, diapers, and much information on first care needed by babies and infants.

The decree that accompanied the Law established a Committee of 9 Ministers, headed by the Minister of Planning and including Health, Education, Justice, Women’s National Service (SERNAM), Finance, Presidency, Labor, Housing. The national technical committee has also been expanded to include all the public services related to children. The preeminence of Health for early child development is expressed in a permanent working group.

The principles of intersectorial approach, equity as a key social goal, focus on education and early childhood, high political commitment and social participation are remarkable aspects of this program that probably will produce outstanding results on the future development of the Chilean society.

National Agenda on SDH. And some lessons of the Chilean experience.

Given the presidential mandate to improve Equity in health as part of the broader objective of improving social Equity, in early 2008, the Chilean Ministry of Health decided to create the Executive Secretariat on Social Determinants of Health, as part of the Subsecretariat of Public Health, within this area an special plan had been create: the “13 pasos hacia la Equidad” (13 steps towards Equity – www.equidad.cl) initiative, aimed at improving the level and distribution of health within the population of Chile. As part of the agenda, six objectives were defined, each of them involving concrete actions aimed at contributing to equity in health in Chile:

Specific objectives of the agenda:

  1. To contribute to the reduction of social inequalities which generate health inequities
  2. To reduce inequities which restrict and limit access to health and health services
  3. To implement actions for the “social inclusion” of excluded groups and territories
  4. To develop competencies on equity and social determinants of health within the Ministry of Health staff
  5. To generate tools for planning, monitoring and evaluation of the SDH and equity in the health sector
  6. To establish bodies and mechanisms for the coordination and integration of various sectors to develop the necessary actions to reduce health inequities

The first of these objectives had been addressed partially through the Chile Crece Contigo that we had already talked about. Another example is the objective 3 had become practical with the implementation of the programs “Vulnerable Counties” and “Vulnerable Neighborhood” focusing on the 96 most vulnerable counties and 68 neighborhood of the country with the goal to promote the reduction of inequities in health in the most communities, by means of interventions aimed at the main barriers of access to health services and to the social protection system, which were identified and prioritized by the community itself.

This Secretariat and his worked until March 2010 promoting a work agenda. We had to make the point that one of the first actions of the new central right party Goverment was to close this important secretariat

Some lessons

The “13 pasos” agenda is also one of few experiences in Chile where the Ministry of Health has been able to play a true leading role. The process of developing and implementing the “13 pasos” agenda influenced the philosophy of people within the ministry of Health but also from other sectors. During the process, we learned some lessons that could be generalizable to others that are involved in similar processes.

  • Lesson 1: In order to strengthen health equity, there must exist explicit political commitment at the highest level
  • Lesson 2: The need for an explicit agenda with incentives
  • Lesson 3: Building trust is a must
  • Lesson 4: Intersectoral relationships are crucial
  • Lesson 5: The community is essential
  • Lesson 6: Training as a strategy for institutionalization

Actual challenges, civil society participation and the future

 

The inequalities in Chile area a huge problem. On income measures for example, the richest 10% earn 36 times more than the poorest 10% and the 20% richest group of Chile share about 50% of the GDP of the country. Taking some health examples, with a very good Infant Mortality Rate of 7.7 as average, there is a 3-fold difference between the less educated and better educated groups. Even more, in life expectancy, the gap increase till 14 and 10 years between the richest and poorest groups, for woman and men respectively. Nevertheless, the worst statistical analysis is that the trends are not diminishing but increasing in the last decades.

In this context we organize and held at Santiago, past 7,8,9 and 15 of October the first Congress on Health and Poverty in Chile, as a voice from the Civil Society to contribute to maintain the health and equity issues and social determinants of health approach into the national agenda. IFMSA was of course involved. It was more concretely, a Health and Equity congress, to widely discuss this issue, the actual policies and problems, gathering civil society, politicians, academicians and other stakeholders with a perspective of future. For Spanish speakers you could enter to our webpage to have more information and access to the presentations. Soon we will have all the conferences online for free access.

At the actual context, the urgent situation and critical inequalities on our country, the civil society is reacting and taking their own responsibility. So different NGOs and young leaders are getting around a platform todiscuss, propose, advocate and create whole society awareness of the needed actions to tackle the terrible inequalities of our country. Heath&Equity will be the future on that. You could check a small presentation with the graphs and a wider analysis and some proposals from the Health&Equity civil society movement in Chile for the future: http://www.saludypobreza.cl/wp-content/uploads/2011/10/Towards-Equity-in-Health.pdf

Do you want to know more about Chilean experience on Health and Equity? Discuss a little bit about? Share your troughs? More than welcome. ccuadrado@saludypobreza.cl

Cristobal Cuadrado

WCSDH in Rio: Medical students’ perspective on the Rio Declaration

The most important output of the WHO World Conference on Social Determinants of Health is the Rio Political Declaration on Social Determinants of Health, which can be downloaded here: http://www.who.int/sdhconference/declaration/en/index.html. In response to the Declaration, the IFMSA delegation to the WCSDH raises some vital issues that the Declaration failed to address. The statement below was distributed to all participants of the conference during the time the Declaration was unveiled in Rio de Janeiro.

The 10-member delegation of the International Federation of Medical Students’ Associations (IFMSA), a unique network of 106 national organizations in 99 countries, was thrilled to be part of this inspirational conference that has no doubt changed us all.

The delegation welcomes the Rio Declaration as it symbolizes a major step in the quest for global health equity. However, we also wish to express some of our concerns regarding the Declaration and the most important points that it missed.

The main problem of the Rio Declaration is that it failed to explicitly tell us how the unfair distribution of power, resources and wealth will be addressed, especially by Member States. The WHO Commission on Social Determinants of Health has been adamant about the need to tackle this lingering issue, as health inequities within and between countries are rooted in power relations and resource maldistribution. We understand that changing the current dynamics of power will not happen overnight. However, we believe that this Declaration could have been the watershed moment for leaders to make a strong commitment in making this world a fairer place.

  1. We believe that democracy is the key instrument in fixing the existing imbalances in power and in ultimately reducing health inequities. However, the Declaration is weak in emphasizing the value of democracy in all processes – from decision-making to evaluation – and at all levels – from community to global level. The Declaration should have encouraged the creation of democratic institutions within and between countries that will allow active engagement among all sectors.
  1. We noted that the Declaration mentioned the line “private sector, safeguarding against conflict of interest” three times. It is established that large multinational corporations wield disproportionately large power in influencing both intermediate (i.e. tobacco, alcohol, unhealthy food, breastmilk substitutes, working conditions) and structural (i.e. intellectual property and trade agreements) determinants of health. The Declaration could have been a perfect opportunity to specifically define the specific role of the private sector in reducing health inequities and to clearly draw the lines governing engagement between government and the private sector.
  1. Global economic governance institutions, such as the IMF, WTO and World Bank, wield disproportionately large power in influencing many of the upstream determinants of health, i.e. through loan conditionalities, free trade agreements, TRIPS+ provisions and agricultural subsidies. We welcome the mention of health impact assessments and call for this to become a mandatory step when creating FTAs and imposing IMF conditionalities. The Declaration should also ask of these powerful institutions the same standards of transparency, accountability and democracy as that urged of Member States.
  1. It cannot be denied that action on social determinants of health will require substantial funding. However, the Declaration is silent about how tackling health inequities will be financed. Commitment to adoption of innovative financing schemes such as progressive taxation on capital gains or extremely-high earners, implementing a financial transactions tax, as well as preventing tax evasion, should have been enshrined in the Declaration.
  1. Although the Declaration recognizes the importance of engaging with civil society, we feel that it should specifically advocate for the creation of spaces for dynamic dialgogue, venues that will enable civil society to be heard and to also directly hear from governments. The writing of the Declaration has been disappointing, as civil society, which could have meaningfully contributed in strengthening the Declaration, was shunned away in the official process. Governments should value the voice of civil society as these groups, having been working on reducing health inequities for many decades, have the capacity to see these defects and propose innovative solutions.
  1. Finally, we would have hoped that the Declaration explicitly include the inclusion of young people and youth organizations such as ours in the movement for action on social determinants of health. As early as now, young people should be made to understand the principles of equity and social determinants to ensure smooth transfer of knowledge and deeds and eventually the sustainability of this global movement. Moreover, youth today has the sheer capacity to effect positive change, a capacity which remains largely untapped. With their innate energy, fresh vision, and advanced grasp of technology, young people, who will be inheritors of global health sooner rather than later, can largely and meaningfully contribute in advancing the movement for “health and equity for all.”

Now, as we all go back to our respective homes, we medical students ask all conference participants to take time to look at the Declaration once more, to reflect on the discussions and lessons of the conference, to consider the voice of civil society and young people, and to think of the next bolder steps that will move us forward in reshaping the distribution of power and combating health inequalities around the world.

On our part, we medical students commit ourselves to continue engaging with all sectors involved in the work towards global health equity, spreading awareness of the social dimensions of health to our fellow young people, mobilizing them to take action in their respective communities and countries, doing our part, little by little, but with courage, constancy, and conviction.

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