PHM-Exch> [PHM NEWS} World Report on Social Determinants of Health Equity
Claudio Schuftan
cschuftan at phmovement.org
Sat Jan 20 05:46:19 PST 2024
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From: David <dlegge at phmovement.org>
Date: Sat, Jan 20, 2024 at 11:20 AM
Will it make a difference?
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<https://mailchi.mp/phmovement/eb154-11_ntds-17630569?e=ade41a541f>
World Report on Social Determinants of Health Equity:
Will it make a difference?
Sixteen years after Closing the Gap in a Generation
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=5c2471ae7c&e=ade41a541f>,
WHO is preparing to release a new World Report on the Social Determinants
of Health Equity. Data from the report, summarised in Document EB154/21
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=428db5f473&e=ade41a541f>
will be reviewed by WHO’s Executive Board, meeting from 22 January 2024.
The data summarised in EB154/21
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=4674443b79&e=ade41a541f>
are confronting; both the levels of inequity and the slow progress in
redressing health inequities since 2008.
EB154/21
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=d776757d1b&e=ade41a541f>
reflects on the (lack of) progress since the 2008 Commission Report. It
concludes that “there has been insufficient attention and action on key
structural determinants such as inequitable economic systems, structural
discrimination including intersecting racism and gender inequality, and
weak societal infrastructure”. It concludes that “efforts to reduce health
inequities have often focused narrowly on the efforts necessary for fairer
health service provision” but there has been less effort on intersectoral
advocacy and collaboration.
EB154/21
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=936034ffe8&e=ade41a541f>
points to the impact of multiple intersecting crises (climate, Covid,
conflict, cost of living) and points to major social and technical
transitions which look set to exacerbate health inequities.
Critical among these 'transitions', although not mentioned in the report,
is the declining faith in the promises of democratic participation and
public good policy dialogue. This appears to reflect the grief and anger of
communities who are left behind by globalisation, linked to the perception
of a parallel governance regime (behind the democratic facade),
characterised by corporate impunity, military adventurism and the
subordination of elected officials through money politics and revolving
doors.
EB154/21
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=fda982cada&e=ade41a541f>
foreshadows 14 specific recommendations to be presented in the new report,
addressing four overarching objectives. The goals of these recommendations
are to:
“address the health effects of hierarchies of power and resource
distribution; addressing systems and policies driving structural
discrimination, including intersecting racism and gender inequality; and
rebuilding weak societal infrastructure to improve living and working
conditions and strengthen social connection” and to provide entry points
for “the health sector to act as an enabler and driver of action at the
structural level”.
Theory of change Why should we expect that these recommendations will
facilitate the adoption of equity policies and the implementation of equity
programs? What were the obstacles to such policies and programs in the past
(including the Commission’s 2008 report) and how will this Report
contribute to overcoming those obstacles?
There is an implicit theory of change evident in EB154/21
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=739f4945ab&e=ade41a541f>,
although not explicitly set out. This theory involves a strengthening and
alignment of various drivers of pro-equity policies and programs,
including:
1. the articulation of a range of pro-equity policies which are relevant
to international and domestic debates around social and economic policies
and programs;
2. the emphasis on community engagement and social participation in
policy processes and creating conditions that maximize the capabilities of
progressive civil society forces to address the social determinants of
health equity; and
3. strengthening the focus on social determinants in health systems and
policy platforms; and developing human capacity in health, social
protection, education, labour, local government and service organizations
to enhance intersectoral efforts to address the social determinants of
health equity; and
4. an emphasis on measurement, research, and publication of the various
indicators of health inequity, discrimination and weak human services.
Putting forward pro-equity policy positions EB154/21 suggests that the
World Report will take pro-equity positions on a number of issues which are
highly contested in global and/or domestic policy debate. This is direct
and significant intervention in policy formation. The authoritative
articulation of such policy positions provides leverage which can be
exercised by advocates for health equity. Instances of such pro-equity
policy positions include:
1. the use of progressive taxation and income transfers to promote
equity and expand domestic fiscal space for universal public services;
highlighting the importance of fiscal space for pro-equity public
investment in fields such as debt relief, development financing;
international cooperation on taxation;
2. highlighting the concept of commercial determinants of health and the
need for regulation to maximize the health-promoting capacity of the
private sector; highlighting the role of public procurement in encouraging
“ sustainable, safe and healthy products and safe and fair labour
standards”;
3. strengthening health equity considerations in global and regional
trade processes;
4. the provision of adequate public funding for infrastructure and
service delivery across health, education, transport, housing, water,
sanitation, and food systems;
5. achieving universal health coverage through progressive health
financing and primary health care approaches; minimizing out-of-pocket
expenditure, and financing health services from pooled government resources;
6. highlighting the need to address and protect the social determinants
of health equity in emergencies, migration and conflict; ensure the rights
of displaced people to access health and social services;
7. ensuring that urban, rural and territorial planning, transport and
housing investments are underpinned by approaches that ensure that housing
and built environments are healthy and accessible;
8. extending basic employment entitlements to precariously employed and
informal workers; highlighting the importance of universal social
protection;
9. recognizing and repairing structures of discrimination, including
those pertaining to gender, race and disability, and addressing the impacts
of colonization, and acknowledging Indigeneity as a determinant of health
and health equity;
10. strengthening support for Indigenous communities in their
stewardship of land and natural resources;
11. articulating the health equity benefits of action on climate change,
biodiversity, and food security.
Failure to name the fundamental drivers of inequity, discrimination,
austerity, and alienation and the obstacles to implementation of pro-equity
policies However, it appears from the summary in EB154/21 that the World
Report will not analyse and address the fundamental drivers of inequity,
discrimination, austerity, and alienation. These include:
1. the evaporation of decent employment associated with trade
liberalisation, technological development, and the emergence of large
corporations, sitting astride global value chains, with the power to extort
concessions from countries as a condition for foreign investment;
2. the impact on small farmers of the protection and subsidisation of
Northern agriculture and the power of giant agribusiness across global food
value chains;
3. the impact of financial liberalisation on the ability of national
governments to manage their own economies, including progressive taxation,
capital controls and fiscal space for social development;
4. the impact of deepening economic inequality and the evaporation of
decent employment on community depression and anger, sometimes manifest in
neo-fascist movements.
The failure to fully document and analyse such drivers weakens the policy
platform being advanced through the World Report and diminishes the
leverage available to the various constituencies advocating for policy
reform across this space.
It also appears from the summary in EB154/21 that the World Report will not
analyse and address the obstacles to the adoption of pro-equity policies
and the implementation of pro-equity programs. These include:
1. the power of ‘market sentiment’ (the voice of international capital)
over elected governments in relation to taxation, public expenditure,
privatisation and marketisation of human services;
2. the impact of money politics and the revolving door (between business
and government) on policy formation;
3. the role of the World Bank and similar agencies in promoting
neoliberal social and economic policies;
4. the role of the IMF and the global private banks in imposing
austerity while refusing to address the causes of unsustainable debt and
currency vulnerability; and
5. the limitations on domestic policy formation which have been embedded
in the global network of multilateral and plurilateral trade and investment
agreements.
The failure to fully document and analyse the obstacles to pro-equity
policy implementation weakens the policy leadership to be provided through
the World Report and diminishes the leverage available to the various
constituencies advocating for policy reform across this space. Building
constituencies which can exercise political pressure on domestic policy
formation and international policy debate It appears that the strategy
underlying the World Report, in terms of driving change, will rely on three
leading constituencies: measurement and research; pro-equity civil society;
health systems and personnel.
*Measurement, research, publication.* The measurement, research and
publication constituency includes the health equity researchers
(epidemiology, social science, policy studies, etc) and the program
monitoring and statistical reporting agencies. The World Report will
underline the importance of continued monitoring of health equity and of
continuing research into the trends and patterns in health equity
(including drivers of inequity and the obstacles to policy action). The
history of debate around health equity suggests that measuring and
publishing (from Virchow to Marmot) makes a difference albeit not
sufficient by itself.
*Civil society.* It is evident from EB154/21 that the World Report sees
civil society advocacy as an important driver of change, including local
communities advocating to local government; international NGOs active in
health equity; and public interest social movements working with those
communities who bear the brunt of inequity, discrimination, and lack of
services.
It is evident that the pro-equity policy positions to be advanced in the
World Report, will provide leverage for such civil society
advocacy. However, such civil society advocacy faces significant
challenges, not least the legal obstacles imposed by many governments on
popular mobilisation and democratic expression.
The basic building blocks of civil society advocacy are the organisations
and networks which bring together the experiences and demands of those who
bear the brunt of inequity. Building a coherent voice capable of impacting
on domestic policy making involves a convergence of different communities
reaching across boundaries, in the light of the shared structural drivers
of their different disadvantage.
In terms of building a coherent civil society constituency capable of
intervening strongly in international policy debate there are many issues
which claim priority and there are boundaries of language, culture, and
context to be breached. However, these NGOs and international networks are
strengthened when they have direct links with grass roots organisations.
If WHO were to pick up the challenge of working with civil society, there
is much that it could do, from Geneva, and from regional and country
offices. However, as a member state organisation, WHO has been very
cautious about collaborating with civil society beyond the sclerosis of
‘official relations’.
*Health systems and personnel.* EB154/21 foreshadows a major policy push to
strengthen the focus on social determinants in health systems and policy
platforms; to integrate the social determinants of health equity in all
health strategies, policies, emergency preparedness and response plans, and
public health laws; to develop human capacity in health, social protection,
education, labour, local government and service organizations to enhance
intersectoral efforts to address the social determinants of health equity.
This vision of health agencies and personnel as advocates for equity
recalls the promise of the Alma-Ata Declaration of 1978 which projected a
scenario of primary health care practitioners and their agencies working
with their communities to address the social determinants of their
health (Newell,
1975
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=304d9ffe51&e=ade41a541f>).
After 30 years of trying to bury or reinterpret the Alma-Ata vision of
primary health care it is encouraging to see this fundamental principle
being recognised.
However, health system managers everywhere are facing needs which outstrip
resources and their employment contracts give them powerful incentives to
focus all their resources on those programmatic needs. Health systems
financiers are likewise preoccupied with patient throughput and while
health promotion units have been allowed to speak about health inequities
(sometimes), they rarely have the resources to back up their rhetoric.
Addressing these conservative incentives will require an outside
constituency, outside the health establishment, demanding a change in
policy; demanding meaningful action towards health equity. This outside
constituency can only come from the communities who have most to gain from
pro-equity policies and programs. Facilitating such voices will be critical
in “leveraging the health sector” for health equity action.
*PHM urges EB members to endorse the pro-equity policies and strategies
foreshadowed in EB154/21 and to strengthen those areas where the World
Report is at risk of glossing over key issues.*
*PHM urges public interest civil society organisations to take full
advantage of the progressive policy platform foreshadowed for the World
Report and build domestic and international advocacy around the development
and implementation of pro-equity policies and programs. *
The full PHM commentary on this item
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=f7741cfc65&e=ade41a541f>
provides
more detail and references. See also Tracker links to previous discussions
of social determinants/social determination
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=71b835bba5&e=ade41a541f>
.
The WHO Tracker 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=bc7acee5d1&e=ade41a541f>
in association with Medicus Mundi International
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=20a50a1af9&e=ade41a541f>,
Third World Network
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and a number of other civil society networks. WHO Watch contributes to
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See the WHO Tracker page for this EB154 session (here
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=aa37425052&e=ade41a541f>).
See PHM’s integrated commentary
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=0f0aa96288&e=ade41a541f>
on the full agenda of EB154 (or read the flipbook version
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