The Commission on Social Determinants of Health (CSDH) framework shows how social, economic and political mechanisms give rise to a set of socioeconomic positions, whereby populations are stratified according to income, education, occupation, gender, race/ethnicity and other factors. These socioeconomic positions in turn shape specific determinants of health status (intermediary determinants) reflective of people’s place within social hierarchies; based on their respective social status, individuals experience differences in exposure and vulnerability to health-compromising conditions. The CSDH framework departs from many previous models by conceptualising the health system itself as a social determinant of health (SDH). The role of the health system becomes particularly relevant through the issue of access, which incorporates differences in exposure and vulnerability, and through intersectoral action led from within the health sector. Arguably the single most significant lesson of the CSDH conceptual framework is that interventions and policies to reduce health inequities must not limit themselves to intermediary determinants, but must include policies specifically crafted to tackle the social mechanisms that systematically produce an inequitable distribution of the determinants of health among population groups. To tackle structural, as well as intermediary, determinants requires intersectoral policy approaches.
Equity in Health
The World Social Forum first met in 2001 in the city of Porto Alegre, Brazil, as a challenge to the World Economic Forum (WEF) and 'claimed to organize an alternative to capitalist neo-liberal globalisation. The author further describes their experience as they scoured for analysis of the World Social Forum, and came across critiques accusing the WSF of being a glorified discussion group for the emerging class of career activists and NGOs, to an incubator for the domestication of possibly explosive actors.
Save the Children’s research compares mortality rates of poor children and rich children in 32 countries. In many countries that are successfully reducing child mortality, progress is concentrated among the poorest and most disadvantaged children. Conversely, in countries making slow or no progress, disparities in life chances between children from the poorest and richest backgrounds tend to be extreme. Since 1990, the global child mortality rate has declined by 28%, which falls short of the target set by Millennium Development Goal (MDG) 4 (a two-thirds reduction by 2015). Still, many high-mortality countries have substantially reduced child deaths, and 19 of 68 high-priority countries are now expected to meet MDG 4. The findings underscore a great gap in reaching the poorest with essential health care, including pre-and post-natal care, skilled attendance at birth, and low-cost prevention and treatment for the major child killers – pneumonia, diarrhoea, and malaria. Save the Children found inequity in child survival to be a persistent and sometimes growing problem in many of the world’s developing countries, where 99% of all child deaths occur.
In the February newsletter we carried stories of the World Social Forum held in January 2007 and called for comment and report from those who attended. In this issue we carry three of the responses, that give a different set of lenses on and expectations of the WSF. They signal aspirations and contradictions that seemed to resonate across the WSF. The WSF offered all the potential of an agenda of social justice, international solidarity, gender equality, peace and defence of the of the environment. This made reports of big business sales of food, corporate signs and overshadowing of local people by international organisations harsh and visible contradictions. But the WSF also gave visibility and support to struggles for health and an opportunity to amplify the call on African Union member states to meet their commitments in health, like the pledge to spend 15% of government spending on health. If the “battle for ideas” is central to the building of alternatives, the WSF taught that it is not only the content of the ideas that count, but who owns and voices them.
This literature review highlights the causes, effects and potential mitigation measures of adult obesity in Africa. The major factors that contribute to obesity include over-nutrition, physical inactivity, change of dietary habits, modernisation, consumption of high-fat, high-carbohydrate foods and increased urbanisation. Despite African women tending to be more obese than men, they are less prone to hypertension, heart disease and type 2 diabetes than men before they reach menopause due to their fat deposition being predominantly sub-cutaneous rather than abdominal. The defining metabolic changes in obesity are decreased glucose tolerance, decreased sensitivity to insulin, hyperinsulinemia and reduced life expectancy. The author highlights that obesity is a controllable behavioural disorder, with regular exercise and sensible eating being the best ways to regulate body fat percentage and maintain a healthy body weight. As it is difficult to treat obesity, efforts in Africa should be directed towards prevention in order to keep it in check.
The United Nations (UN) High-Level Meeting on Non-communicable Diseases (NCDs) has helped raise awareness about the burden of NCDs, but the authors of this article caution that the real work of preventing and controlling NCDs must begin. They put forward several important steps that must be taken immediately. Governments need to implement the commitments in the Political Declaration that call for acceleration of the Framework Convention on Tobacco Control (FCTC), a global public health treaty focused on reducing the five million deaths per year caused by tobacco use. In addition, national plans to address NCDs need to be developed and NCDs need to be incorporated into the United Nations’ Millennium Development Goals. Clear, effective, and achievable targets to reduce NCDs - developed with input from health experts and civil society - need to be established and monitored by the World Health Organisation. And, importantly, global and national funding needs to be mobilised by governments, the private sector and civil society so that these plans can be effectively implemented, particularly in low- and middle-income countries. Moreover, the global health and development community must commit to greater collaboration across sectors and disease groups. Vertical interventions that target one disease at a time must be folded into comprehensive horizontal health programmes that promote overall health and wellness across the individual’s lifespan.
This report outlines five main goals for the post 2015 agenda: ending poverty by 2030; promote gender quality; improve access to quality education, water and sanitation; promote good governance; and build strong effective institutions. It posits five transformative shifts as crucial for achieving all five goals: leave no one behind; put sustainable development at the core; transform economies for jobs and inclusive growth; build peace and effective, open and accountable institutions for all, and forge a new global partnership. Like the Millennium Development Goals, the report suggests that targets would not be binding, but should be monitored closely. The indicators that track them should be disaggregated to ensure no one is left behind and targets should only be considered ‘achieved’ if they are met for all relevant income and social groups. The Panel recommends that any new goals should be accompanied by an independent and rigorous monitoring system, with regular opportunities to report on progress and shortcomings at a high political level. It also calls for a data revolution for sustainable development, with a new international initiative to improve the quality of statistics and information available to citizens.
A new species of mosquito has been discovered by South African researchers that might be a malaria vector. The authors of the report note that ‘understanding the vectors is absolutely key; if we don't do anything about mosquitoes, we will never do anything about malaria.’ The previously unknown species was discovered during field studies in and around rural villages in northern Malawi near the town of Karonga, on the western shore of Lake Malawi. The new species is related to the major African malarial vector, Anopheles funestus, but the ‘jury is still out on ... whether it carries [the] malaria [parasite]," Coetzee, one of the authors, said. The Anopheles funestus Giles group of mosquitoes has nine known African species, and ‘although the members of the Anopheles funestus group may be similar in morphology [its form and structure], their efficiencies as malaria vectors vary greatly,’ the report said. Coetzee said it was important to ascertain whether Anopheles funestus Giles was a malaria vector or not, but this could only be determined after further research.
This report from Population Action International examines progress made towards achieving the goal of reproductive health and rights for all by 2015, agreed at the 1994 International Conference on Population and Development (ICPD). Key achievements include a significant increase in contraceptive use, and higher secondary school enrolment rates among girls. However, significant challenges remain, notably: high unmet need for effective contraception and protection from HIV/AIDS and other sexually transmitted infections (STIs); continuing high levels of maternal mortality; high rates of unsafe abortion; and an acute and growing resource shortfall, with many clinics experiencing stockouts (zero supplies) of contraceptives, safe motherhood kits and other reproductive health essentials.
Concepts of fair distribution of health, such as equity of access to medical care, may not be sufficient to equalise health outcomes but, nevertheless, they may be more practical and effective in advancing health equity in developing countries. This study used a framework for relating health equity goals to development strategies allowing progressive redistribution of primary health care resources towards the more deprived communities is formulated. The framework is applied to the development of primary health care in post-independence Namibia. In Namibia health equity has been advanced through the progressive application of health equity goals of equal distribution of primary care resources per head, equality of access for equal met need and equality of utilisation for equal need. For practical and efficiency reasons it is unlikely that health equity would have been advanced further or more effectively by attempting to implement the goal of equality of health status. The goal of equality of health status may not be appropriate in many developing country situations; instead, a stepwise approach based on progressive redistribution of medical services and resources may be better.