Health in All Policies: Taking Inter-sectoral Action for Equitable and Sustainable Health

PHABC 2013 Annual Conference and General Meeting

Addressing the Social Determinants of Health through Health in All Policies: A Regional Perspective

By Dr Kira Fortune Regional Advisor – Determinants of Health

Pan American Health Organization/ Regional Office of WHO

4-5 November, 2013

Contents

1. An Overall Panorama of Health Inequity in the Americas

2. PAHO’s Mission and Values: Equity and the Social Determinants of Health

3. Addressing the Social Determinants of Health: An Essential Factor in Breaking the Cycle of Health Inequity

4. Advances made in the Region of the Americas

5. Putting Equity at the Center of Post-2015

6. Conclusion

1. An Overall Panorama of Inequity in the Americas

On a Positive Note

•With three years to go before the date established for achieving the MDGs, the Latin American and Caribbean region has made significant progress

•The region has made strides in reducing extreme poverty, under-nutrition, hunger and undernourishment and child mortality •Life expectancy in the Region increased from 69.2 to 76.1 between 1980 and 2011 •Data from the Region positively reflect a low rate of child malnutrition at around 4 percent and high immunization rate against measles at 93 percent •Between 1990 and 2007, the under-five mortality rate was more than halved from 55 to 26 per 1,000 individuals

Source: ECLAC, 2013

Inequity at a Glance

The Red Line between Washington, D.C. and Shady Grove, Md. has 17 metro stops spanning 30 miles and an estimated nine-year difference in life span

• Poverty and inequity are two of the greatest challenges of this century

• 2.7 billion people world-wide live on

less than $2 per day

• Six out of ten of the world’s poorest people are women

• Stark differences in economic

opportunities explain significant health inequities between and within countries

• There is a 36-year-gap in average life

expectancy between Malawi and Japan

• The life expectancy in Dominican Republic is 73.5 whereas in Haiti it is 62.2 –a gap of 11.3 years within the same island

Sources: Robert Wood Johnson Foundation, 2011 Source: World Health Organization, 2011

Median income: $143,500

Median income: $58,526

The Greatest Challenge of the 21st Century: Poverty and Inequity

• Despite the fact that Latin America and the Caribbean is a middle income region, the Region is one of the most unequal region in the world with regards to income levels (PAHO, 2012)

• Recent evidence demonstrates that almost 1 in 5 residents of the Region lives on less than 2 US$ a day (World Bank, 2010)

• Currently 120 million people in the region of the Americas as a whole do not have access to health services due to economic reasons (PAHO, 2009)

PAHO: Health in the Americas, 2012

poorer

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Income Growth by Income Terciles: Region of Americas

1980-2008

• LAC is the most urbanized region in the

developing world, with 77 percent of its population living in cities

• Major cities in the United States (Atlanta, Washington D.C. & New York) have the highest levels of inequality in the country, similar to Abidjan & Nairobi

• In Belize, Guatemala and Peru over 50% of the urban population lives in slums, while in Barbados, Chile, Guyana, and Uruguay, less than 10% of the urban population lives in slums

• Infant mortality ranges from 6.5% in one central area to 16% in another part of Greater Buenos Aires, Argentina (Bernardini, 2009)

The Continuing Challenge of Rapid Urbanization in the Americas

Urbanization in the Region of the

Americas

Source: UNHabitat 2009

2. PAHO’s Mission and Values: Poverty, Equity and the Social

Determinants of Health

Mission in Action

• PAHO is strongly committed to putting equity firmly on the agenda

• Equity and the Social Determinants of Health are key priorities in Health Agenda for the Americas 2008-2017

• Addressing inequities through the approach of The social determinants of health and Health in All Policies is one of the objectives in PAHO’s Strategic Plan

Category 3: Determinants of Health and Promoting Health Throughout the Life Course Outcomes Outcome Indicators

OCM 3.5 - Increased leadership of the health sector to address the social determinants of health and health promotion.

Number of countries implementing the Rio Political Declaration on the social determinants of health

Number of countries and territories integrating social determinants of health within their health sector programs

OPT 3.5.1 - Implementation of the WHO Health in All Policies Framework for National Action including intersectoral action and social participation to address the social determinants of health

Number of countries implementing the Health-In-All-Policies Framework for National Action

OPT 3.5.2 - Social determinants of health applied as a strategic approach in all PAHO Programs

Number of PAHO entities integrating social determinants of health in planning and monitoring processes.

OPT 3.5.3 - Countries enabled to generate equity profiles to address the social determinants of health

Number of countries and territories producing equity profiles addressing at least two social determinants of health

OPT 3.5.4 - Countries enabled to scale up local experiences using health promotion strategies to reduce health inequity and enhance community participation and empowerment

Number of countries implementing health promotion strategies to reduce health inequities and increase community participation

OPT 3.5.5 - Countries enabled to address Post 2015 Development Agenda on health responding to the social determinants of health.

Number of national consultations specifically addressing the Post 2015 Development Agenda on health.

PAHO’s STRATEGIC PLAN: 2014-2019

3. Addressing the Social Determinants of Health: An

Essential Factor in Breaking the Cycle of Health Inequity

Addressing the Causes…

In 2008, The Commission on the Social Determinants of Health launched Closing the Gap in a Generation, putting equity firmly on the global agenda The Commission made three over-arching recommendations:

1) To improve daily living conditions 2) To tackle the inequitable

distribution of power, money and resources

3) To measure and understand the problem and assess the impact of action

Breaking the Cycle of Inequity: The Role of Social Determinants of Health

• Looks at the whole picture of countries (local, national, and community) addressing the inter-related factors that impact the overall health

• Encourages public policies to be evaluated and changed to improve health and well-being

• Enhances the elimination of gaps in health outcomes between social groups

• Allows public health professionals to look for solutions outside the health care systems to improve health

• Provides a framework for countries to improve the health of people while empowering and encouraging fair opportunities across the life course

• Contributes to achieving the Millennium Development Goals

Age, sex & hereditary

factors

Determinants of Maternal Health

Woman’s level of

education

Family and peer

influences

Income of family

Place of

residence-

urban vs. rural

Gender Norms

Ethnicity,

class

status, and

social

exclusion

Cultural

and

religious

values and traditions

Access to

affordable

and high

quality

health services

National

legal and

policy

environments

Addressing Maternal Health and its Determinants of Health

Countries are moving forward to Implement a social determinants approach, informed by the recommendations of the Commission:

• Spain championed social determinants of health as one its priorities during its EU Presidency. A situation analysis, commissioned by the EU Commission was published and now a relevant reference in the field

• African region endorsed a regional strategy on the

social determinants of health

• In South America, UNASUR’s Council of Ministers of Health identified tackling the Social Determinants of Health in the region as one of five priorities in the organization’s 2010-2015 Plan of Action

The Approach of the Social Determinants of Health

Source: World Health Organization, 2011

A Key Milestone for the Region: The Global Conference on the Social Determinants of Health

Through public consultation, Member States identified Five Key Pillars

– Governance to tackle the root causes of health inequities

– Promoting participation

– The role of the health sector

– Global action on social determinants

– Monitoring progress

A key outcome of the Global Conference was the Rio Political Declaration

• Ottawa Charter for Health Promotion (1986): – Set the foundation for global

health promotion – Defined as “the process of

enabling people to increase control over, and to improve, their health”1

Image: WHO (1986). Ottawa Charter for Health Promotion Logo

1. WHO (1986). Ottawa Charter for Health Promotion.

2. WHO (1988). Adelaide Recommendations : healthy public policy.

Ottawa Charter for Health Promotion

The Helsinki Statement adopted in June, 2013

We call on governments to fulfill their obligations to their peoples’ health and well-being by

taking the following actions:

• Commit to health and health equity as a political priority by adopting the principles of Health in All Policies and taking action on the social determinants of health.

• Ensure effective structures, processes and resources that enable implementation of the Health in All Policies approach across governments at all levels and between governments.

• Strengthen the capacity of Ministries of Health to engage other sectors of government through leadership, partnership, advocacy and mediation to achieve improved health outcomes.

• Build institutional capacity and skills that enable the implementation of Health in All Policies and provide evidence on the determinants of health and inequity and on effective responses.

• Adopt transparent audit and accountability mechanisms for health and equity impacts that build trust across government and between governments and their people.

• Establish conflict of interest measures that include effective safeguards to protect policies from distortion by commercial and vested interests and influence.

• Include communities, social movements and civil society in the development, implementation and monitoring of Health in All Policies, building health literacy in the population

The Helsinki Statement adopted in June, 2013

4. Advances Made in the Region of the Americas

• Education has proven to be an essential factor in lessening inequality between low-skilled and high-skilled labor wages

• In 2006, equality and personal protection was a main priority of Chile’s administration

• Creating a universal minimum state pension, extending free health care for numerous illnesses, and investing in early childhood development some of the priorities.

• These efforts have put Chile on track to accomplish all eight of the UN’s Millennium Development Objectives by 2015, making it the only Latin American and Caribbean country to do so

• The percentage of people living in poverty in 2001 was 37.5%

• By 2009 poverty had been reduced to 24.9 percent

• It is estimated that the Bolsa Familia program, which focused on health and education contributed to 54% of the decline in poverty from 2001 to 2009

• Brazil met its first Millennium Development Goal by reducing the proportion of the population living in extreme poverty prior to the 2015 deadline

Countries’ Efforts to address Inequity through SDH and HiAP

• At 15.5 percent of GDP, Costa Rica’s overall spending on the social sector is higher than the Latin American average of 12.5 % (World

Bank, 2007)

• Key investments have been made in health and education securing access to services for the population as a whole

• Costa Rica has low levels of poverty and inequality, the highest life expectancy in the region and a significant level of social mobility

Ch

ile

Co

sta

Ric

a B

razi

l

Health in All Policies: The Case of Mexico

Approximately 70% of the adult Mexican population has an excessive body weight. The prevalence of obesity and overweight in Mexican school children aged 5–11 is also high: one child in four is overweight

The National Agreement for Healthy Food

• An example of concerted inter-sectorial actions amongst 7 ministries and 6 institutions, involving academics, civil society and the private sector to modify family diets, eating habits and physical activity, and, thus to try address the rise of obesity

• This strategy is three-fold as it specifically targets children, addresses supply and

access to healthy food and beverages and promotes physical activity • The strategy is a comprehensive approach to fight increased obesity levels by

encouraging action and regulation on the production, marketing, advertising and education in terms of a healthy lifestyle

Observatories in the region opens up opportunities for training, research and monitoring, serving as dissemination points for best practices in policy by focusing on legislation, regulation, public policies and international health policy.

CARMEN NCD Policy Observatory : a platform for the network of American countries and institutions engaged in the systematic analysis of non-communicable disease (NCD) policies

Virtual Campus: A PAHO/WHO public health technical cooperation strategy serving key actors

Regional Health Observatory: An institutional resource to facilitate access to health data, statistics and information from the Region of the Americas

EQUIDAD listserv: Specialized resource serving 65,000 in 170 countries designed to disseminate information, promote communication and interdisciplinary links on Equity, Health and Human Development

Building and Sharing Evidence

To make the most neglected communities seen and heard in meeting the targets of the MDGs

Going beyond ‘the averages’: addressing the unjust illusion resulting from averages in health statistics

Enhancing inter-sectoral action

for participatory local development by working with Ministries of Health and national & local governments

The Goal of this Initiative is:

Faces, Voices and Places

Networks

Normative work

Technical Cooperation

On-going and Future Initiatives

Support countries in Sustainable Development and

Health Equity (SDH) discussions, teaming up with key

academic, scientific and technological institutions

•Regional Consultation and Seminar Series on HiAP

•Develop extensive HiAP case studies based on preparatory

work for Helsinki

• Present Action Plan on HiAP to Directing Council in 2014

•Special Edition on the Social Determinants of Health

• High-Level Regional Consultation on Social Determinants

of Health

•Develop work plan with collaborating centers

•Work in close collaboration with the Rockefeller Foundation,

UNDP and NIH

5. Putting Equity at the Center of Post-2015

Through public consultation, Member States identified Five Key Pillars:

A key outcome of the Global Conference was the Rio Political Declaration

Rio Political Declaration adopted by Member States in September, 2011

Governance to tackle the root causes

of health inequities

Promoting participation

The role of the health

sector

Global action on social

determinants

Monitoring progress

Putting health at the heart of the

Sustainable Development agenda

Making the links for Rio+20

Department of Public Health and Environment

Future that We Want adopted by Member States in June, 2013

We call on governments to fulfill their obligations to their peoples’ health and well-being by

taking the following actions:

• Commit to health and health equity as a political priority by adopting the principles of Health in All Policies and taking action on the social determinants of health.

• Ensure effective structures, processes and resources that enable implementation of the Health in All Policies approach across governments at all levels and between governments.

• Strengthen the capacity of Ministries of Health to engage other sectors of government through leadership, partnership, advocacy and mediation to achieve improved health outcomes.

• Build institutional capacity and skills that enable the implementation of Health in All Policies and provide evidence on the determinants of health and inequity and on effective responses.

• Adopt transparent audit and accountability mechanisms for health and equity impacts that build trust across government and between governments and their people.

• Establish conflict of interest measures that include effective safeguards to protect policies from distortion by commercial and vested interests and influence.

• Include communities, social movements and civil society in the development, implementation and monitoring of Health in All Policies, building health literacy in the population

The Helsinki Statement adopted in June, 2013

Framework Defining the Post-2015 UN Development Agenda

An opportunity to put a focus on:

• Health in All Policies

• Equity

• Social Determinants of Health

• Non-Communicable Disease

• Universal Health Coverage

Messages Emerging from Consultations on Post-2015

• Equity should be “hardwired” into the Post-2015 goals through disaggregating indicators and targets at all levels

• While keeping the health MDG targets, the increasingly apparent challenges of NCDs and their risk factors should also be included, with clear indicators

• Universal Health Coverage: An overarching goal including access to medicines, stronger health systems, people-centered services, nutrition, health promotion and disease prevention, quality of care, and evidence-based medicine as well as the social determinants of health

Botswana 5-6 March

2013

• The Region has changed – this must be taken into account

• Call for a new development model based on structural change for equality and environmental sustainability

• Need to measure better

• Global governance for sustainable development based on fair trade, technology transfer, international financial reform and new funding mechanisms, promotion of South-South cooperation and strengthening of social participation mechanisms

Bogota

7-9 March 2013

Bringing it All Together….

Relevant Tools for the Latest Developments on:

http://new.paho.org/mdgpost2015/

http://new.paho.org/tierra/

Sustainable Development Goals and Post-2015

Conclusion

Collaborating with

Ministries of Foreign Affairs

Align and capitalise on existing regional

evidence and programs

Putting the

Helsinki Statement into Practice

Working in an Inter-

Sectoral Manner

Putting Equity, the Social Determinants of Health and HiAP at the Centre of Post-2015

Ministries of Foreign Affairs are driving the post-2015 process. Collaboration is key ensure that equity and SDH are put firmly on the agenda

Policy coordination is essential - integration of health in all policies whether it be education, environment, employment or transportation-focused

There are a number of regional initiatives addressing SDH and HiAP. Those should form part of the Post-2015 dialogue

This is a ‘hands-on-experience’ putting Health in All Policies to work. An opportunity to implement the Helsinki Declaration

Thank you