Addressing the Social Determinants of Health Challenges and Pathways

Transcription

1 Addressing the Social Determinants of Health Challenges and Pathways Thelma Narayan Centre for Public Health and Equity, SOCHARA Bangalore, India Member, People s Health Movement (PHM) Nuffield Council on Bioethics Symposium, 22 nd June 2011, London, United Kingdom

2 Plan of Presentation The first 10 slides offer brief reflections about the societal determinants of health and health inequalities The following 5 slides provide an overview of health indicators from India which are dependent on the SDH Together they highlight the nature of the challenges The last 15 slides are a snapshot of responses by the community, civil society, governments and academics over the past decade indicating critical pathways and partnerships to address health inequalities

3 Social relevance & community orientation of global health efforts? Ethics and Responsibilities. Is there need for a paradigm shift?

4 Tackling the Social Determinants of Health in an Era of Globalization There is an urgent need to address the root cause of inequalities in disease, disability and health. Social conditions in which people live and work or the social determinants of health. Source: WHO Commission on Social Determinants of Health (WHO- CSDH), Need for policies and practice that tackle the underlying determinants of health inequalities, within a framework of cross-cutting rights.

5 Poverty, Inequality, Discrimination Development Health Health is a determinant of Development UNDP 2005 Development is a determinant of Health The deeper determinants of both need to be addressed as a priority at global, national and local levels

6 Corporate led globalization, Neo-liberal economic reforms, Negative macro-policies Adversely affect the social majority, nationally & globally Livelihoods, Incomes, Food security, Increased conflict, War and violence, Access to water, Access to health care, Environmental degradation,

7 Macro-policy driven politicoeconomic determinants, backed by unprecedented wealth, and concentration of power Enhance existing socially embedded determinants and inequalities due to Gender Race, Ethnicity, Caste Language Belief system Disabilities, Mental Illness

8 Disparities hampering progress are systematic, reflecting hierarchies of advantage and disadvantage and public policy choice UNDP, 2005

9 Global Inequalities High income countries represent 15 % of the world s population 40% of the world s population, ie 2.5 billion people living on less than $2 a day, account for 5% of the global income UNDP 2005

10 Trade, Development and Health Over 2/3 rd of the poor are small farmers and agricultural laborers Unfair trade undermines their livelihood Led by the EU and USA developed country agricultural subsidies are over $ 350 billion a year, ie, almost $ 1 billion a day, supporting large farmers and corporate agri-business For a fraction of the cost, universal education, health and water for all can be achieved. UNDP, 2006

11 International organisations & institutions Roles and responsibilities for Global Health

12 INDIA:? shining global example Overall employment growth in 1990s was 2/3 rd to half of 1980 For agricultural labourers, bulk of poor in India, rate of growth of real wages per annum almost halved in the 1990s, compared to 1980s. Worsening of working conditions of labourers in the informal sector and agriculture in past decade Open unemployment serious JOBLESS GROWTH - Jeyarajan and Swaminathan, 2003

13 Women 53% Men- 24% Children- 70% ( 6-59 months) ANAEMIA Source: India, NFHS- 3, , Key Findings. Prevalence of Anaemia above 10 % is a public health emergency. What are the ethics and responsibilities underlying this situation?

14 Trends in Child Nutrition in India Percentage of Children under age three years. Nutritional Status NFHS 2 NFHS 3 Stunting (Low height for age) Wasting ( Low weight for height) Underweight ( Low weight for age) National Family Health Survey (NFHS ) NFHS ; NFHS Source: India, NFHS 3, , Key findings. In Bihar the child nutrition situation worsened from to

15 National Health Goals & MDGs - India X FY Plan 2007 NPP 2010 MDG 2015 Current Infant Mortality Rate (IMR) 45 < (SRS 2005) Maternal Mortality Ratio (MMR) 200 < (SRS 01-03) Total fertility Rate (TFR) Institutional deliveries 80% 80% 40.7 (NFHS III) Source: NFHS 3; SRS 2005 X FY 10 th Five Year Plan, NPP National Population Policy, MDG Millenium Development Goals, SRS Sample Registration Scheme, NFHS National Family Health Survey

16 India s Health Indicators State/UT Large inter state variations IMR SRS 2005 MMR SRS TFR SRS 2005 Kerala Madhya Pradesh Orissa Tamil Nadu Uttar Pradesh All India

17 What are the people saying? Less Food No water No job

18 Meeting Challenges in the New Millennium: with a People Centric Approach With people back into the centre of primary health care The public back into public health and health systems and community voice and power back into health policy discourse & decisions, As subjects & co-creators not objects

19 People s Health Assembly 2000 (PHA) 1978 Alma - Ata Declaration Health For All by WHA - Three NGO leaders recognized the need to involve poor people in health decision making 's (Early) 10 Years after Alma Ata RIGA Conference ACHAN Consultation International Peoples Health Council Struggle for liberation from poverty, hunger and unfair socioeconomic structures 1990's (Late) PHA Core Group Formed by 8 Organizations The G National Coordination Committees And working groups began to emerge eg. India

20 Over 2000 participants in 5 peoples health trains Mobilization across 19 states Adopted 20 point Indian People s Charter Launched the Jan Swasthya Abhiyan, Campaign for Health for All Now Health as a Fundamental Human Right

21 Globalization Of Health From Below The First Global People s Health Assembly In 2000 December, 1454 health activists from 75 countries met in Savar, Bangladesh to discuss the challenge of attaining Health for All, Now! Over 250 Indian delegates attended

22 Globalization Of Health From Below The People s Charter for Health, 2000 Health is a social, economic and political issue and above all a fundamental human right. Inequality, poverty, exploitation, violence and injustice are at the root of ill health and the deaths of poor and the marginalized people.

23 Campaign on the Right to Health Care PHM - India Public Hearing State and district action, from 2000 onwards Indian Social Forum, November 2006 Second National Health Assembly February 2007 Critical collaboration with National Rural Health Mission Participation in the World Social Forum

24 Socio Epidemiology of Diarrhoea 3 rd SDTT symposium CHC 2003

25 Asian Social Forum, January 2003, Hyderabad JSA members organized workshops on: 1. The Right to Health Care 2. Environment and Health 3. Tobacco and Health 4. The People s Health Movement

26 Asian Social Forum January 2003, Hyderabad - INDIA

27 World Social Forum, January 2004, Mumbai Workshops on health rights & determinants by JSA and PHM

28 Campaigns on Gender Issues (an example from among several campaigns) Campaign Against Sex Selective Abortion or Female Foeticide 2001 onwards Campaign on Violence against Women as a Public Health Challenge 2000 onwards Women s Access to Primary Health Care People s Tribunal on Population Policies th International Women and Health Meeting 2005 Gender and Power Issues in Medical Education Women s Health Charter Participants converge from many streams, groups, not only PHM/ JSA

29 Health Policy Dialogue and Action Adopted by Karnataka State Cabinet in 2004 Interim Report in April 2000 Final Report in April 2004 Accepted by Govt of Karnataka igher Level Implementation Committee setup

30 MAINSTREAM DEVELOPMENTS IN PUBLIC HEALTH WITH PARTNERSHIP OF ALTERNATIVE SECTOR

31 National Health Policy Interaction - INDIA with the National Rural Health Mission (NRHM) nwards Members of Task Forces and Advisory Committees Shifted focus from Demography to Public Health and community involvement Community Monitoring of the Health System. People s Rural Health Watch Community Action for Health National ASHA Mentoring Group Universal Access to Health Care Recently a National Mental Health Policy Group

32 Understanding why? INEQUALITY MARGINALISATION Policy Analysis NEW ECONOMIC POLICIES Liberalization, Privatization, Globalization ECONOMIC CONSTRAINTS COMMERCIALIZATION OF HEALTH CARE Inadequate control of Veterinary use Environment pollution as reservoir Inadequate treatment guidelines Over use/ misuse Cost Irrational drug use Inadequate provider education Inadequate Primary Health Care Antibiotic Resistance Inadequate infection control Malnutrition, Immunity Lack of patient education Combination & substandard drugs Consumer Behavior Weak Public Health Systems Poor monitoring, surveillance Decline in Research funds UNSUSTAINABLE DEVELOPMENT AND DISPLACEMENT INTERNATIONAL TRAVEL DECREASED INVESTMENT IN SOCIAL SECTOR INTERNATIONAL TRADE: WTO/IPR

33 What can be done. Policy Action Political Awareness and support Tackling Environ mental challenges Local/national/regional global action Veterinary Use Guidelines Hospital waste disposal. Antibiotic treatment guidelines/ schedules Controlling OTC sales Cost control Rational prescribing Provider / prescriber education Strengthening Primary Health Care Antibiotic resistance People s need oriented economic/trade policies Strengthening infection control in health care institutions Strengthening Nutrition Promoting rational consumer education Multifaceted approaches for Behavioral change Controlling combination drugs Strengthening Public Health Systems Improving surveillance Promoting more research on the problem Safe drinking water, sanitation Equitable tourism options Increased investment in health, nutrition, social welfare, education sectors Countering commercialization of health care

34 Globalization Of Health From Below Globalizing Solidarity Folk from over 80 countries at the Second People s Health Assembly, Cuenca, Ecuador, 2005

35 Second People s Health Assembly (PHA2) July 2005, Cuenca - Ecuador PHM Evaluation, 2004

36 Conclusion Working together towards greater social justice in global health is imperative. The pathways are many. What will be our path? Is there a role for community and civil society engagement? What are the barriers in reaching the Health for All Goal?