<br>From: "David Woodward" <<a onclick="return top.js.OpenExtLink(window,event,this)" href="mailto:David.Woodward@neweconomics.org" target="_blank">David.Woodward@neweconomics.org</a>><br>Subject: Commission on Social Determinants of Health - a Golden Opportunity!<br>
<br>As is well known by now, the Commission on Social Determinants of Health has finally published its report, which can be downloaded at <a onclick="return top.js.OpenExtLink(window,event,this)" href="http://www.who.int/social_determinants/final_report/csdh_finalreport_2008.pdf" target="_blank">http://www.who.int/social_determinants/final_report/csdh_finalreport_2008.pdf</a> . 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.<br>
<br>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!<br>
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<p style="MARGIN: 0in 0in 0pt"><b><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">What the Report of the Commission on Social Determinants of Health says about:</font></span></b></p>
<p style="MARGIN: 6pt 0in 0pt 1.5in; TEXT-INDENT: -0.25in"><span lang="EN-GB" style="FONT-SIZE: 10pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><font face="Times New Roman"><b><span lang="EN-GB" style="FONT-SIZE: 10pt">Health Care</span></b><span lang="EN-GB" style="FONT-SIZE: 10pt"></span></font></p>
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<p><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman"><i><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">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.</font></span></i></font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><i><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">It should be emphasised that <b>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</b>. 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.</font></span></i></p>
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<p style="MARGIN: 0in 0in 0pt"><b><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">Health Care</font></span></b></p>
<p style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">The Commission is strongly critical of recent <span>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. </span></font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><font face="Times New Roman"><span lang="EN-GB" style="FONT-SIZE: 10pt">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. U</span><span lang="EN-GB" style="FONT-SIZE: 10pt">ser charges for health services are unacceptable, and health care should be financed from general taxation or mandatory insurance, minimising out-of pocket spending. <span>Intended beneficiary groups should be included in all aspects of policy and programme development, implementation, and evaluation.</span></span></font></p>
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<p style="MARGIN: 0in 0in 0pt"><font face="Times New Roman"><span lang="EN-GB" style="FONT-SIZE: 10pt">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 </span><span lang="EN-GB" style="FONT-SIZE: 10pt">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 c<span>ommunity health workers.</span></span></font></p>
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<p style="MARGIN: 0in 0in 0pt"><b><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">Other Health-Related Services</font></span></b></p>
<p style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">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. <span>The state</span> also has <span>a clear responsibility </span>to e<span>nsure access to water and sanitation, which is essential to life, and wholesesale privatisation of water should be discouraged. </span>Access to clean water should not be limited by ability to pay, and c<span>ross-subsidies should be used where cost recovery is necessary.</span></font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><b><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">Economic Models of Development</font></span></b></p>
<p style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">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 <span>limited investment in infrastructure and human resources, reducing state capacity</span>. 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. </font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><font face="Times New Roman"><span lang="EN-GB" style="FONT-SIZE: 10pt">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</span><span lang="EN-GB" style="FONT-SIZE: 10pt"> appropriate social policies, <span>economic growth</span> brings little benefit to health or health equity. P<span>rogress towards health equity requires addressing economic inequality, including inequity in public financing</span>, <span>and the evidence suggests that income redistribution is a more efficient means of reducing poverty.</span> Systems should be built to ensure that no-one's income falls below a minimum healthy level.</span></font></p>
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<p style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">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. <span>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. </span></font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">Policy coherence and inter-sectoral action for health – "health in all policies" – are essential, and <span>renewed government leadership is urgently needed to balance public and private sector interests.</span> </font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><b><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">Markets and the Corporate Sector</font></span></b></p>
<p style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">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. <span>Even where goods and services can be efficiently and equitably provided through the private sector, government regulation</span> <span>is vital, and efforts</span> 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.</font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><font face="Times New Roman"><span lang="EN-GB" style="FONT-SIZE: 10pt; COLOR: black">The impact of voluntary initiatives on corporate behaviour is inevitably limited, and "</span><span lang="EN-GB" style="FONT-SIZE: 10pt">corporate responsibility" </span><span lang="EN-GB" style="FONT-SIZE: 10pt; COLOR: black">is often little more than cosmetic, lacks enforcement, and entails little evaluation. Corporate</span><span lang="EN-GB" style="FONT-SIZE: 10pt"> <i>accountability</i> may provide a better means of ensuring positive effects of business activities</span><span lang="EN-GB" style="FONT-SIZE: 10pt; COLOR: black">. The Commission suggests </span><span lang="EN-GB" style="FONT-SIZE: 10pt">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.</span></font></p>
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<p style="MARGIN: 0in 0in 0pt"><b><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">Employment and Livelihoods</font></span></b></p>
<p style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">The Commission condemns inequitable, exploitative, unhealthy and dangerous working conditions, and<span> </span>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.</font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><font face="Times New Roman"><span lang="EN-GB" style="FONT-SIZE: 10pt">Fair employment and decent work should be a central focus of development</span><span lang="EN-GB" style="FONT-SIZE: 10pt"> <span>strategies, and economic</span> and social policies should provide secure work and a living wage, taking in line with the cost of health needs. Full employment <span>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.</span></span></font></p>
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<p style="MARGIN: 0in 0in 0pt"><font face="Times New Roman"><span lang="EN-GB" style="FONT-SIZE: 10pt">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 <span>four core principles</span></span><span lang="EN-GB" style="FONT-SIZE: 10pt"> – </span><span lang="EN-GB" style="FONT-SIZE: 10pt">freedom of association and the right to collective bargaining; freedom from forced labour; the effective abolition of child labour; and non-discrimination in employment. </span><span lang="EN-GB" style="FONT-SIZE: 10pt">Child labour can be reduced by i<span>ncreasing poor households' income and ensuring quality schooling. The state should guarantee the right to collective action among formal and informal workers. </span></span></font></p>
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<p style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">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.</font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><font face="Times New Roman"><span lang="EN-GB" style="FONT-SIZE: 10pt">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.</span><span lang="EN-GB" style="FONT-SIZE: 10pt"> </span></font></p>
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<p style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">Efforts should be made to improve working conditions in the informal sector as <span>part of a coherent economic and social policy including social protection, education, and public sector strengthening. </span>OHS policy and programmes should be applied to all workers, and <span>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.</span></font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">The Commission emphasises that changes in the operation of the global economy are necessary for its recommendations on employment to be implemented. (See <b><i>Globalisation</i></b> in part 2.)</font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><b><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">Social Protection</font></span></b></p>
<p style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">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.</font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">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</font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">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. <span>Donors and international organisations have an important role to play in building capacity for social protection.</span></font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-SIZE: 10pt"><font face="Times New Roman">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 <b><i>Globalisation</i></b> in part 2.)</font></span></p>
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