Written by Dirk Van der Roost

Next week the 1st WHO World Conference on Social Determinants of Health (SDH) will take place in Rio de Janeiro. Civil society also organizes a number of pre-events in the run-up to the conference. The Conference is part of a broader process that started with the work and report of the WHO Commission on SDH and the 2008 World Health Report on Primary Health Care. Two important resolutions on SDH and PHC were then adopted at the World Health Assembly of 2009. And now there’s the Rio Conference. “Samba time” for SDH advocates? That is the hope, at least.

The WHO background document is indeed quite promising and pleads for tackling the root causes or health inequities: “The bulk of the global burden of disease and the major causes of health inequities, which are found in all countries, arise from the conditions in which people are born, grow, live, work, and age. These conditions are referred to as social determinants of health, a term used as shorthand to encompass the social, economic, political, cultural, and environmental determinants of health. The most important determinants are those that produce stratification within a society — structural determinants — such as the distribution of income, discrimination (for example, on the basis of gender, class, ethnicity, disability, or sexual orientation), and political and governance structures that reinforce rather than reduce inequalities in economic power. These structural mechanisms that affect the social positions of individuals constitute the root cause of inequities in health. The discrepancies attributable to these mechanisms shape individual health status and outcomes through their impact on intermediary determinants such as living conditions, psychosocial circumstances, behavioral and/or biological factors, and the health system itself.

The rationale for action on social determinants of health rests on three broad themes. First, it is a moral imperative to reduce health inequities. Second, it is essential to improve health and well-being, promote development, and reach health targets in general. Third, it is necessary to act on a range of societal priorities — beyond health itself — that rely on better health equity.”

The current draft of the Rio Declaration is less ambitious, and carefully avoids terminology such as ‘power relations’ or ‘social injustice’. Nevertheless, the text is consistent and the different draft versions have improved over time. A paragraph on trade and medicines has been introduced, the ‘social protection floor’ has found its rightful place in the document, impact assessment of policies on SDH gets attention and the principles of Primary Health Care have been acknowledged. There’s no mention though of the broader trade (and trade agreements’) impact on social services and tax-raising capacity in the least developed countries. The huge responsibility of the (still hardly regulated) financial sector is not mentioned so far, an unforgivable omission. The same is true for the work of the task force on innovative financing or the enormous potential of a Financial Transaction Tax. Unsurprisingly, the People’s Health Movement is preparing an alternative Declaration.

Let’s focus on the positive side though: there’s clearly a new dynamic. Lots of case studies and country examples are circulating in the virtual world. The Brazilian government expects the biggest bunch of ministers from all over the world since Alma Ata, gathering around a broad health theme (although the setting could have something to do with it too). Ministers of Health will attend, obviously, but also Ministers of Social Affairs, Finance and Employment… The health sector is developing ideas and a leverage mechanism to promote equity and societal change, even beyond health.

Public Health people and MDs at all levels will more than before be confronted with difficult choices on how to spend best their precious time: by seeing patients, managing the health system – keeping their own house in order – and/or linking up with (local) governance and other health related sectors.

The Conference will take place at Sofitel. Anything less than a 5 star approach to combat extreme poverty and social injustice won’t do next week.

Dirk Van der Roost (ITM)

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