We are less than six weeks away from the World Conference on Social Determinants of Health  convened by the World Health Organization (WHO) and the Brazilian government (October 19-21).   The organization of this event started over a year ago and there have been different preparatory events, including a web-based consultation on the background document and WHO-regional consultations.

The aim of the conference is to provide a global platform for dialogue on how the recommendations of the WHO Commission on Social Determinants of Health (2008) could be taken forward.  Organizers expect that Member States and stakeholders will share experiences on policies and strategies to reduce health inequities.  Specifically, the intention of this event is to draw lessons learnt and to catalyse coordinated global action in five key areas.

  • governance to tackle the root causes of health inequities: implementing action on social determinants of health;
  • promoting participation: community leadership for action on social determinants;
  • the role of the health sector, including public health programmes, in reducing health inequities;
  • global action on social determinants: aligning priorities and stakeholders;
  • monitoring progress: measurement and analysis to inform policies to build accountability on social determinants.

Organizers announce that the conference will be attended by ministers of health, foreign affairs, the environment and other sectors; representatives of international agencies, philanthropic institutions and civil society organizations; leading academics and technical experts; and representatives from the private sector. The diverse profile of participants is rather unusual for a WHO conference; these events usually revolve around specific diseases.  The organizers anticipate that the most important outcome  of the conference will be the  Rio Declaration on Social Determinants of health. It is hoped that the declaration will build high-level international support and momentum for the further development and implementation of national policies to address social determinants of health.

Expectations for the conference are running high, particularly when the aim  is to advance on the three main  recommendations set by the WHO Commission in 2008: a) improve daily living conditions b) tackle the inequitable distribution of power, money, and resources c) measure and understand the problem and assess the impact of action. Each recommendation poses major and different challenges.

Understanding the problem, measuring and assessing impact is the most accessible one, as it can be achieved without changing existing structures and organizations. It is basically the job of technical experts who have to produce theoretical frameworks and measure indicators – something that WHO has done for many decades. At least two publications from WHO are moving in this direction: Equity, social determinants and public health programmes (2010); and Social determinants approaches to public health: from concept to practice (2011).

Improving the living conditions of populations,  the second recommendation, requires concerted development action that goes beyond health care. Economic and trade policies should be aligned with social services policies, not only at country level but also at international/global  level.  And as we all know, it is easy to emphasize the need for alignment  but extremely difficult  to achieve.  One example is the lack of alignment between international development cooperation policies and national policies to improve access to health care services.  Through bilateral and multilateral aid and the work of NGOs, European countries support national polices in southern countries to advance access to essential drugs. However, the same countries also confiscate generic drugs shipments destined for southern countries passing through their ports, with the justification of trade policies and violation of trade agreements.  These types of inconsistencies can certainly be highlighted by the health sector but need to be addressed and challenged in different fora.

Tackling the inequitable distribution of power, money, and resources is the most challenging of the three recommendations and goes to the heart of the concept ‘social determinants of health’. Whereas issues of power at the global level are of relevance, we must not forget that there are also issues of power within countries and specific societies. Tackling the distribution of power also entails dealing with the asymmetries between the state and citizens, particularly in post-conflict and fragile states.  Serious and effective action to tackle power requires changing the structures and institutions we currently have.  Will the powerful abide to a conference resolution in which they agree to give up power for the sake of equity? Don’t hold your breath.

Which actions need to be taken to improve people’s  living conditions and how should the distribution of power be tackled? These sorts of vital issues have certainly sparked major debates in recent months, particularly between global civil society and multilateral organizations. The criticism of several civil society organizations on the draft background document for the Rio Conference reveals it.

History has again and again taught us that tackling power involves social struggle. The recent history of Brazil  also enlightens us in this respect: the social struggle for the right to health advances there through an alliance of citizens and progressive politicians. It is therefore so important that Rio hosts the World Conference on Social Determinants.  Let’s hope that in addition to the Rio resolution, we will also achieve the following outcome: a renewed and expanded global alliance of citizens and progressive politicians  committed to  the right to health and equity.

Walter Flores, Emerging Voice from Guatemala.

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