PHA-Exch> A synopsis of the full CSDH report: part 1

[Claudio Schuftan]

From: "David Woodward" <David.Woodward at neweconomics.org>
Subject: Commission on Social Determinants of Health - a Golden Opportunity!

As is well known by now, the Commission on Social Determinants of Health has
finally published its report, which can be downloaded at
http://www.who.int/social_determinants/final_report/csdh_finalreport_2008.pdf.
There is a great deal of very valuable material in it not only on
health
systems and policies, but also on economic policies, globalisation and
global governance. Unfortunately, this is played down in the Executive
Summary, limited in the recommendations it makes, and virtually absent from
the official WHO press release - and consequently from all of the media
coverage we've seen so far.

To redress the balance, we are attaching a (wholly unofficial) "synopsis",
drawing together and summarising what the main text of the report says in a
number of key areas. (Take it from us, it is much more interesting than the
Executive Summary!) Anything anyone can do to highlight these aspects of the
report would be invaluable - it has some of the best ammunition we've had
for years!

*What the Report of the Commission on Social Determinants of Health says
about:*

·         *Health Care*

·         *Other Health-Related Services*

·         *Economic Models of Development*

·         *Markets and the Corporate Sector*

·         *Employment and Livelihoods*
·         *Social Protection*

*While the Commission makes a number of specific recommendations, these are
constrained by its mandate, and as a result do not include many suggestions
and proposals included in the body of the report, or address specific issues
which are clearly identified as necessary if the Commission's objective of
"closing the gap in a generation" is to be fulfilled. At the same time,
because of the very complex and inter-connected nature of influences on the
social determinants of health, material relevant to a number of key issues
is spread across several sections of the report. The following is an attempt
to draw the material in the report together, in summary form, under a number
of thematic headings, highlighting the Commission's suggestions and
proposals, and the specific needs it identifies, as well as its formal
recommendations.*

**

*It should be emphasised that this synopsis has no official status, that it
has been compiled entirely independently of the Commission and its
secretariat, and that it should in no way be attributed to them. While the
contents are intended to reflect what the report says on each subject, some
selectivity has been inevitable, and the emphasis undoubtedly reflects the
priorities of the writer.*



*Health Care*

The Commission is strongly critical of recent health-sector reforms, which
it sees as a product of broader economic influences and driven by
international agencies, commercial actors, and medical groups. These reforms
have resulted in health care becoming increasingly commodified,
commercialised and fragmented, and promoted a narrow technical/medical
focus. This has undermined the development of comprehensive primary health
care, and generated a stark and growing divide between over- and
under-consumption of health-care services between the rich and the poor
worldwide.



Health-care systems should be designed and financed to ensure equitable,
universal coverage and access, allowing everyone who needs health services
to use quality services, with adequate human resources. Health systems
should be based on the primary health-care model, combining locally
organised action on the social determinants of health with strengthened
primary care, and should focus at least as much on prevention and health
promotion as on treatment. Where universal services cannot be achieved
immediately, services disproportionately benefiting disadvantaged groups may
be prioritised in the short term. User charges for health services are
unacceptable, and health care should be financed from general taxation or
mandatory insurance, minimising out-of pocket spending. Intended beneficiary
groups should be included in all aspects of policy and programme
development, implementation, and evaluation.



The report also criticises the IMF's Medium-Term Expenditure Framework
(MTEF) as prioritising very low inflation and conservative fiscal policy
over poverty and health needs, leading to underinvestment in the human
capacity critical for health-care systems; and it warns that global health
initiatives may skew priorities and exacerbate human resource scarcity.
Investment in medical and health personnel should be increased, and efforts
made to balance health-worker density in rural and urban areas, for example
through use of community health workers.



*Other Health-Related Services*

Education, quality housing, clean water and sanitation, as well as health
and health-care, are human rights. The report condemns commercialisation of
health services and education, which should be governed by the public
sector. The state also has a clear responsibility to ensure access to water
and sanitation, which is essential to life, and wholesesale privatisation of
water should be discouraged. Access to clean water should not be limited by
ability to pay, and cross-subsidies should be used where cost recovery is
necessary.



*Economic Models of Development*

The development model pursued since the 1980s has been the target of a great
deal of deserved criticism. Structural adjustment had a severe adverse
impact on key social determinants of health across most participating
countries; and market-oriented economic policies have contributed to the
dispersion of regional performances in life expectancy. It is not clear that
such policies produced the anticipated benefits, or that the health and
social costs were justified. The over-reliance of these programmes on
markets to solve social problems has proved damaging; and they have limited
investment in infrastructure and human resources, reducing state capacity.
There is growing demand for a new approach to social development, moving
beyond an overriding focus on economic growth to look at building well-being
through a combination of growth and empowerment.



The Commission finds that the relationships among globalisation, growth, and
poverty reduction are deeply problematic, noting widespread challenges to he
view that economic growth alone can provide a solution to global poverty,
and the decline in the income share of the poorest 20% of the population in
many countries over the last 15 years. Without appropriate social
policies, economic
growth brings little benefit to health or health equity. Progress towards
health equity requires addressing economic inequality, including inequity in
public financing, and the evidence suggests that income redistribution is a
more efficient means of reducing poverty. Systems should be built to ensure
that no-one's income falls below a minimum healthy level.



The role of governments through public sector action is fundamental to
health equity, and the State has a responsibility to guarantee a
comprehensive set of rights and ensure fair distribution among population
groups. An empowered public sector, based on principles of justice,
participation and inter-sectoral collaboration, is needed to underpin action
on the social determinants of health and health equity. This requires
strengthening the core functions of government and public institutions,
nationally and sub-nationally.



Policy coherence and inter-sectoral action for health – "health in all
policies" – are essential, and renewed government leadership is urgently
needed to balance public and private sector interests.



*Markets and the Corporate Sector*

While recognising the potential benefits of markets to health, the
Commission also highlights their adverse effects, including economic
inequality, resource depletion, pollution, unhealthy working conditions, and
increased consumption of dangerous and unhealthy goods. Even where goods and
services can be efficiently and equitably provided through the private
sector, government regulation is vital, and efforts are needed to ensure
that private sector activities and services (eg production and patenting of
medicines, and health insurance) contribute to health equity rather than
undermining it.



The impact of voluntary initiatives on corporate behaviour is inevitably
limited, and "corporate responsibility" is often little more than cosmetic,
lacks enforcement, and entails little evaluation. Corporate
*accountability*may provide a better means of ensuring positive
effects of business
activities. The Commission suggests disclosure standards for companies on
where products have been produced and with what employment standards.
Consideration could also be given to internationally coordinated changes to
company law, to require publicly quoted companies to pursue a broader set of
social and environmental objectives rather than maximising shareholder
value.



*Employment and Livelihoods*

The Commission condemns inequitable, exploitative, unhealthy and dangerous
working conditions, and  calls for employment conditions conducive to
well-being, including safe, secure and fairly paid work, year-round work
opportunities, and healthy work-life balance for all, with effective worker
protection and measures to reduce stress and exposure to material hazards.



Fair employment and decent work should be a central focus of
development strategies,
and economic and social policies should provide secure work and a living
wage, taking in line with the cost of health needs. Full employment requires
integrated economic and social policies, including employment generation, eg
through public works, local procurement policies, income-generation and
support to small, medium and micro enterprises.



The Commission calls for progressive fulfilment of global labour standards.
While standards should be graduated, recognising the lower standards
developing countries are able to achieve, there should be progressive upward
convergence of standards over time. The starting point should be the four
core principles – freedom of association and the right to collective
bargaining; freedom from forced labour; the effective abolition of child
labour; and non-discrimination in employment. Child labour can be reduced by
increasing poor households' income and ensuring quality schooling. The state
should guarantee the right to collective action among formal and informal
workers.



The Commission supports progressive development and implementation of
binding codes of practice in relation to labour and occupational health and
safety (OHS). Mechanisms should also be explored to create cross-country
wage agreements, initially at a regional level.



Government policy and legislative support are required to rebalance work and
private life, providing parents the right to time to look after children,
access to childcare regardless of ability to pay, flexible working hours,
paid holidays, parental leave, job share, and long-service leave.
Encouragement could be given to shorter working hours in high-income
countries. Government policy and legislation are also needed to create more
security in different working arrangements.



Efforts should be made to improve working conditions in the informal sector
as part of a coherent economic and social policy including social
protection, education, and public sector strengthening. OHS policy and
programmes should be applied to all workers, and should be extended to
include work-related stress and harmful behaviours. OHS components should be
included in employment creation programmes, and in regulation of
subcontracting and outsourcing.



The Commission emphasises that changes in the operation of the global
economy are necessary for its recommendations on employment to be
implemented. (See *Globalisation* in part 2.)



*Social Protection*

Social protection should be provided to all people across the lifecourse,
and should include unemployment, sickness, and disability benefits and
social pensions. Universal (rather than targeted) approaches are important
for dignity and self-respect, can enhance social cohesion and social
inclusion, and may be more politically acceptable. Governments should build
towards universal social protection systems, increasing the generosity of
benefits over time towards a level that is sufficient for healthy living,
and gradually protecting against a more comprehensive set of risks.
Targeting should be used only as a back-up for those who slip through the
net of universal systems.



A concerted effort is needed to develop realistic solutions to social
protection of migrants, asylum seekers and refugees. Attention should also
be given to the needs of people with disabilities, including fighting
discrimination by employers



In developing countries, social protection should be embedded in Poverty
Reduction Strategies. Social protection systems can be developed gradually
through pilot projects, successful pilots being rolled out nationally,
starting with the most deprived regions. Donors and international
organisations have an important role to play in building capacity for social
protection.



As for employment, the Commission emphasises that changes in the operation
of the global economy are necessary for its recommendations on social
protection to be implemented. (See *Globalisation* in part 2.)
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