PHM-Exch> [PHM NEWS] Important steps forward on Social Determinants of Health WHO EB

Wed Feb 1 23:07:55 PST 2023

From: People's Health Movement <dlegge at phmov
New Operational Framework promised

View this email in your browser
<https://mailchi.mp/phmovement/sdh?e=125964ddcc>
Important steps forward on Social Determinants of Health

WHO's Executive Board, meeting in Geneva this week will review progress in
the development of the World Report on the Social Determinants of Health
Equity and the Operational Framework for addressing SDH and measuring
progress (reported in EB152/22
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=2cf3b0ef67&e=125964ddcc>).

It is clear from this report that WHO is doing some excellent work on the
social determinants of health equity.

The proposed operational framework for monitoring action and progress will
give a major boost to public health officials and practitioners working to
overcome widening inequities in population health status. It is clear from
the report that many countries are already working on collecting and
disseminating better data. As better data comes available there will be
more opportunities to use such data to strengthen political will for action.

The planned World Report will likewise give a major boost to policy
discussion around social determinants and health equity and contribute to
building the various constituencies seeking action.

EB152/22
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=3cfe62f954&e=125964ddcc>
describes a variety of useful projects at the global, regional, national
and local levels. The DG and relevant Secretariat staff are to be
congratulated.

However, PHM urges the relevant staff to give closer attention to two major
issues which are not well encompassed in either EB152/22 or the draft
framework:

   -

   The potential role of comprehensive primary health care in building
   civil society pressure for action on the social determinants of health
   inequity; the need to appreciate more deeply the agency of civil society;
   -

   The need to give closer attention to the social determination of health
   inequities; the processes, forces and dynamics which reproduce the social
   determinants of health.

We also comment below on some perplexing remarks in the draft operational
framework about ‘opportunities for transformational change’.
Primary Health Care

Neither EB152/22 nor the draft framework recognize the vision of Alma-Ata
regarding the role of the health sector, in particular the role of primary
health care practitioners and organisations, in working with their
communities to identify, analyse and respond to the factors in their lives
and environments which shape their health and well-being. This is
particularly clear if the Alma-Ata Declaration is reviewed in the light of
WHO’s ‘Health by the People’
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=779f7b7c67&e=125964ddcc>
by Kenneth Newell (1975) which included a range of case studies where
primary health care practitioners, organisations and programs were directly
involved in engaging with the forces shaping their health (and which
informed the development of the Alma-Ata Declaration).

There are many contemporary examples which also demonstrate the potential
power of comprehensive primary health care in driving action on the social
determinants of health, including in indigenous health, in women’s health,
in the AIDS/HIV field, and in health care provision under oppression.

Unfortunately, since PHC has been reconceptualized as subordinate to UHC,
the focus of WHO commentary on PHC has been restricted to its role in
ensuring access to the benefit packages of UHC.

The agency of the people is fundamental to democracy. Both documents in
review focus largely on the agency of government and construct the public
as the objects of policy.

An exception is the excellent passage on page 32:

*“Finally, while local people and communities play a central role as agents
of change, they are often not engaged in developing, reviewing, and
implementing recommendations from policy and scientific writings that aim
to identify priorities related to SDH conditions and SDH actions.
Governments and partners need to work better together and strengthen
community engagement, while civil society groups and community members can
lead community engagement, participation, and advocacy efforts focused on
identifying challenges and needs related to SDHE and priorities for
action.”*

However, the connection is not made to the vision of comprehensive primary
health care.
Social determinants and social determination

It is regrettable that WHO refuses to acknowledge the critics, largely from
Latin America, who point to the limitations of the concept of social
determinants and urge attention also to social, political, and economic
determination; in other words, the structures, forces, and dynamics which
reproduce the social determinants.

The references in para 22 to the commercial determinants of health,
including harmful products and commercial practices is appreciated but the
discussion is very timid. The prevailing regime of economic governance is
driving economic inequality (and health inequity). This regime includes
trading relationships which mediate unequal exchange and support the net
flow of value from South to North. It includes global value chains
controlled by transnational corporations which support a global race to the
bottom in terms of jobs, employment conditions and environmental
protection. It includes a regulatory regime of selective liberalisation:
liberalisation of trade and investment but monopolisation of knowledge and
brutal constraints on the movement of people.

The reference to what was then the promise of a new international economic
order (NIEO) in the Alma-Ata Declaration reflected the need to go beyond
high level generalities (eg ‘commercial determinants’) to articulate quite
specific reforms to global economic governance that were seen then as
critical prerequisites for Health for All. The implication was clear that
if PHC practitioners and their communities want to engage with the
processes which reproduce their poverty, food insecurity, lack of urban
infrastructure, etc here are some specific policy reforms to advocate for.

The 2014 Declaration of Santa Cruz
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=0993cf1e95&e=125964ddcc>:
‘For a new world order for living well’ sets out a comparable agenda for
economic reform in the current period. See also the address by Evo Morales
at the same conference, ‘For a global brotherhood among the peoples’
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=b932f7f7f7&e=125964ddcc>.
See also the G77 Havana Declaration
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=773bcaa845&e=125964ddcc>
of 27 Jan 2023.

It is unfortunate that WHO should so carefully avoid questions such as Why
food insecurity? Why the lack of funding for WASH? Why the failures of
mitigation and adaptation in climate change?

   -

   How are changes in global food systems being driven by global food
   corporations (and the continued protection of Northern agriculture) which
   has the effect of displacing small farmers who migrate to informal urban
   settlements where they can't find jobs and cannot access basic urban
   infrastructure?
   -

   What are the drivers of capital account liberalisation which forces
   countries to allocate precious foreign currency to purchase US Government
   bonds to ‘insure’ against speculative attacks on their currency and as a
   consequence, those resources are not available for urban infrastructure but
   serve to sustain a strong US dollar and hence cheaper imports for US
   consumers?
   -

   How is it that tight control of intellectual property prevents
   technology transfer (solar panels, vaccines, basic phones) and protects the
   market share and pricing power of largely Northern based transnational
   corporations?

The planned report could provide the opportunity to discuss these debates.
The report needs to go beyond general remarks about 'the actions of
commercial actors' and describe and analyse the underlying dynamics of such
'actions'. Hopefully the planned chapter will do this.

The summary of Chapter 2 indicates that it will highlight key policies and
interventions that can reverse the tide in widening inequality. It promises
that key obstacles will be addressed in Chapter 2. But it does not make
sense to speak of identifying 'key policies and interventions' and
confronting ‘key obstacles’ without explicating the processes of social
determination, the structures, forces and dynamics which reproduce the SDH?

There is a discussion on page 23 of the draft framework regarding the
intersection of different influences such as climate change and low prices
on small farmers or Covid-19 on low wage workers. This latter example
points to the complex realities of the political economy of work, including
precarious employment, lack of health insurance, and the gendered and
racialized division of labor.

We appreciate the passage on page 8 of the draft framework which
distinguishes between downstream SDH conditions and upstream structural
determinants.

*"While some countries are collecting and monitoring data on SDH
conditions, they more often focus on “downstream” SDH conditions, such as
education or income, rather than “upstream” or structural SDH conditions,
such as measures of political economy, structural racism, and other forms
of discrimination."*

Hopefully the World Report will elaborate on these ideas.
Racism, sexism, and bigotry

We appreciate the reference on page 15 of the draft framework to:

*"... a growing body of research [that] documents the powerful influence of
racial- and ethnicity-based stigma, racism, and discrimination on health.
The pandemic raised awareness about the importance of addressing structural
racism and ethnicity-based discrimination, including by investing in data
disaggregation by race and/or ethnicity as well as other determinants that
can help to unpack the compounding and intersecting drivers of exclusion.”*

While structural racism is recognised as a fundamental determinant of
health, further attention is needed on how racism is embedded and
reproduced at different levels of social organization, such as individual,
interpersonal, and institutional. Racism can be ingrained in social
institutions at the neighborhood level such as schools, banks, and
hospitals. The entrenchment of social determinants at a collective level
impacts the agency and lives of individuals within those collectives and
should be an important focus for policies aiming to reduce health
inequalities. Hopefully the World Report will explore these issues of
scale.

The writers of the World Report are urged to dig deep. In a world of
obscene economic inequality, misogyny, racism, and bigotry all contribute
to social division, divert energy into conflict, and obscure the shared
reality of an economic regime which cultivates deepening inequality,
degrades quality of life and obstructs action on global warming.
Opportunities for transformational change associated with intersecting
global crises

There are several references in the draft operational framework to
‘opportunities for transformational change’ associated with the
intersecting global crises.

This idea is poorly developed. Yes, progressive scenarios are conceivable
but 'opportunities for transformation' implies pathways opening up where
the barriers to change are reduced and the forces for change are
strengthened. Reassuring scenarios are not the same as real opportunities.
The case needs to be made that there are real opportunities associated with
these crises.

See for example the discussion of climate change as 'an opportunity for
transformational change' towards health equity. We look forward to seeing
this scenario worked through more closely in the final version of the
framework.

*PHM urges Member States to encourage and support the Secretariat in this
work.*
------------------------------

See our more detailed commentary on this item here
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=72effe65a5&e=125964ddcc>.
The Tracker page for EB152 is here
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=90067ff028&e=125964ddcc>
.

The WHO Tracker
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=582349f2f2&e=125964ddcc>
and PHM item commentaries are produced as part of WHO Watch which is a
project of the People's Health Movement
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=5bf25d15af&e=125964ddcc>
in association with Medicus Mundi International
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=eec672effa&e=125964ddcc>,
Third World Network
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=830162d00c&e=125964ddcc>
and a number of other civil society networks. WHO Watch aims to contribute
to democratising global health governance, through new alliances, new
information flows and by broadening the policy discourse.

You can support WHO Watch by publicising the Tracker; by inviting others to
subscribe to the WHO Watch Updater (subscribe here
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=2354de6835&e=125964ddcc>);
and by following us on Twitter via @PHMglobal and @WorldHealthWatch.

To provide feedback on this newsletter please write to editor at phmovement.org
.
[image: WHO Tracker]
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=43e9712372&e=125964ddcc>
[image: PHM Global]
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=769373c731&e=125964ddcc>
[image: PHM Global]
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=d829fa257a&e=125964ddcc>
[image: PHM]
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=79c8605056&e=125964ddcc>
*Copyright © 2020 People's Health Movement, All rights reserved.*
You are receiving this email because you subscribed to the WHO Watch
Newsletter.
Not subscribed? Sign up here
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=e7190e8172&e=125964ddcc>
.

*Our mailing address is:*
WHO Tracker / People's Health Movement
PHM c/- Viva Salud
Chaussee de Haecht 53
Brussels B-1210
Belgium
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://phm.phmovement.org/pipermail/phm-exchange-phmovement.org/attachments/20230202/5aa3f243/attachment-0001.htm>