<div dir="ltr"><div class="gmail_default" style="font-size:large"><br></div>From: <b class="gmail_sendername" dir="auto">People's Health Movement</b> <span dir="auto"><dlegge@phmov</span><br><div class="gmail_quote"><div class="msg-7643723642493309629"><u></u>
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<h1 style="text-align:center;display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:26px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal">Important steps forward on Social Determinants of Health</h1>
<p style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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 <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=2cf3b0ef67&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">EB152/22</a>). </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">It is clear from this report that WHO is doing some excellent work on the social determinants of health equity.</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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.</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020"><a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=3cfe62f954&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">EB152/22</a> describes a variety of useful projects at the global, regional, national and local levels. The DG and relevant Secretariat staff are to be congratulated.</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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:</p>
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<p dir="ltr" role="presentation" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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;</p>
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<p dir="ltr" role="presentation" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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.</p>
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<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">We also comment below on some perplexing remarks in the draft operational framework about ‘opportunities for transformational change’.</p>
<h2 style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Primary Health Care</h2>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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<a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=779f7b7c67&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank"> ‘Health by the People’</a> 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).</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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.</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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.</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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.</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">An exception is the excellent passage on page 32:</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020"><i>“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.”</i></p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">However, the connection is not made to the vision of comprehensive primary health care.</p>
<h2 style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Social determinants and social determination</h2>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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.</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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.</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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.</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">The 2014 <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=0993cf1e95&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">Declaration of Santa Cruz</a>: ‘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,<a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=b932f7f7f7&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank"> ‘For a global brotherhood among the peoples’</a>. See also the <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=773bcaa845&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">G77 Havana Declaration</a> of 27 Jan 2023.</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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?</p>
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<p dir="ltr" role="presentation" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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?</p>
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<p dir="ltr" role="presentation" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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?</p>
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<p dir="ltr" role="presentation" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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?</p>
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<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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.</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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?</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">We appreciate the passage on page 8 of the draft framework which distinguishes between downstream SDH conditions and upstream structural determinants.</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020"><i>"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."</i></p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">Hopefully the World Report will elaborate on these ideas. </p>
<h3 dir="ltr" style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:20px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Racism, sexism, and bigotry</h3>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">We appreciate the reference on page 15 of the draft framework to:</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020"><i>"... 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.”</i></p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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. </p>
<h2 style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Opportunities for transformational change associated with intersecting global crises</h2>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">There are several references in the draft operational framework to ‘opportunities for transformational change’ associated with the intersecting global crises.</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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.</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020"><b>PHM urges Member States to encourage and support the Secretariat in this work.</b> </p>
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<p style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">See our more detailed commentary on this item <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=72effe65a5&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">here</a>. The Tracker page for EB152 is <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=90067ff028&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">here</a>.</p>
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