CHALLENGES TO IMPLEMENTING THE "SOCIAL DETERMINANTS FOR HEALTH EQUITY" (SDHE) AGENDA IN COUNTRIES
MEETING REPORT : SHORT VERSION
Convened by WHO with support from the Department of Health, England, United Kingdom. Held at the Chateau de Penthes, Geneva, Switzerland 2-3 June 2008
Contact: Nicole Valentine [email protected]
Daniel Albrecht [email protected]
The World Health Organization’s Medium-term Strategic Plan (2008-2013) set forth the aim of
crafting health policies, systems and programmes that pursue health equity by tackling the social determinants of health (action on the social determinants of health equity). Multi-faceted action on the social determinants of health equity (SDHE) was recently called for by the WHO Commission on Social Determinants of Health 2005-2008 (hereafter “the Commission”), which submitted its final report to the WHO Director-General in June 2008. This report summarizes knowledge to help countries and WHO better understand the implementation challenges to be faced in pursuing health equity around the world. The implementation issues and challenges presented in the report were summarized for and discussed at an expert meeting in Geneva in June 2008. Experts also discussed how WHO could better support ministries of health in implementing this agenda. This meeting was organized by the Department of Ethics, Equity, Trade and Human Rights (ETH) in collaboration with regional office focal points.
Thanks are due to colleagues from the ETH Department, the WHO regional office focal points, and to country partner focal points for their contributions to the meeting agenda. Special thanks for contributions on early drafts of the agenda are due to: Anjana Bhushan in the WHO Western Pacific Regional Office; Don Matheson (Chairman); Orielle Solar (consultant); Nick Drager, Eugenio Villar and Ritu Sadana of the ETH Department; and last, but not least, representatives from Canada, Chile, England and Sri Lanka – key country partners who provided support to the Commission’s Country Work programme of the CSDH.
This short report was written by Nicole Valentine, Daniel Albrecht and Orielle Solar. Thank you to Nuria Quiroz for formatting the document and Liza Shurik for copy-editing.
Valuable input on initial drafts of the report was provided by Don Matheson and Carolyn Peterken of MANNET Consulting. Thank you to the presenters for providing comments on the summaries of their presentations. The report was sent for comment to all participants and their input and suggestions were gratefully received.
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CONTENTS
STATEMENT FROM THE CHAIRMAN ..................................................................... 1
EXECUTIVE SUMMARY ........................................................................................... 2
INTRODUCTION........................................................................................................ 7
BACKGROUND LITERATURE ................................................................................. 9
MEETING AGENDA AND PARTICIPANTS ............................................................ 11
Developing the agenda........................................................................................................................................ 11
Participants ......................................................................................................................................................... 11
MEETING DISCUSSIONS ....................................................................................... 12
Part 1: Framing SDHE Implementation Challenges ....................................................................................... 12
Part 2: Challenges and Support Needs of Countries Adopting the SDHE Agenda ...................................... 14 Political support ............................................................................................................................................... 14 Financing.......................................................................................................................................................... 15 Organizational structures, responsibilities and powers .................................................................................... 16 Monitoring and Evaluation (M&E) .................................................................................................................. 17
Part 3: WHO Support to Countries .................................................................................................................. 18 Recommendations to WHO.............................................................................................................................. 19 (I) GLOBAL LEADERSHIP AND ADVOCACY ......................................................................................... 19 (II) NORMS, STANDARDS AND GUIDANCE FOR COUNTRIES ........................................................... 21 (III) COUNTRY LEVEL OFFICE SUPPORT ............................................................................................... 23
ANNEX 1. AGENDA AND LIST OF PARTICIPANTS
REFERENCES......................................................................................................... 34
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STATEMENT FROM THE CHAIRMAN
The initiative discussed in this report is not just another health programme, but rather a fundamental re-thinking of the values and goals of the health and other sectors and the way in which they work together to achieve the aspirations of society. This new perspective adds a strategic dimension to existing programmes and policies – a strategy that focuses on equity as an outcome and looks at a broad range of societal actors both in and outside the health sector.
The experiences of countries at this meeting have been grounded in key global policy statements over the past four decades including: the Alma Ata Declaration on Primary Health Care in the 1970s; the Ottawa Charter for Health Promotion in the 1980s; the WHO Intersectoral Action for Health for the 21st Century in the 1990s; and finally, in the new millennium, the Bangkok Charter for Health Promotion, the EU’s Health in All Policies, the WHO Commission on Social Determinants of Health (hereafter “the Commission”) and the new move to revitalize primary health care (PHC).1 There is now sufficient experience in these countries to testify to the credibility and success of tackling social determinants as a means for improving health and addressing health equity. However, this experience still needs further development and translation in all countries. The new knowledge and experiences need to be widely disseminated so that the benefits of the approach can be more universally and systematically applied. In particular, it is crucial that less developed countries (LDCs) play a central role in this development and translation, which focuses on addressing both intra- and inter-country equity.
Today, in 2008, there is a window of opportunity with the release of the Commission report and the revisiting of the primary health care agenda to mobilize the transformational changes required to address health equity. The approach of pursuing actions that improve health equity through tackling the social determinants of health is essential to achieving society’s wider goals, including stability, sustainability and increased quality of life for all its citizens. This approach challenges the health sector to strengthen the very backbone of the health system with a call to develop health programmes and policies that strive to work toward comprehensive societal goals that go beyond the narrower objectives of the health sector.
This approach will be particularly effective in dealing with the immediate global health challenges posed by climate change and the food crises, providing an opportunity to build a broader global response to the SDHE. It is time to move beyond the theory and apply it to the problems of the day.
Don Matheson July 2008
1 Adapted from the Public Health Agency of Canada (2007).
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EXECUTIVE SUMMARY
This report describes the challenges of implementing an SDHE agenda for decision-makers in different countries as well as recommendations on the potential actions WHO can take to support these countries. These challenges and recommendations were discussed in a meeting of experts held in Geneva in June 2008, organized by the ETH Department together with WHO regional office focal points. The meeting objectives were: (i) to gain greater clarity on the scope of practical implementation challenges and (ii) to outline the support needs of countries for meeting these challenges.
Meeting context
This was the first global meeting organized by WHO to discuss the challenges of implementing the SDHE agenda at the country level. The meeting built on the cumulative experience of the Commission, which presented its report to the WHO Director-General in June, but did not discuss the Commission recommendations themselves. The meeting was held to support the ETH Department in transforming the broad mandate of Strategic Objective 7 of the WHO 2008-2013 Medium-term Strategic Plan (MTSP) into a departmental workplan. Strategic Objective 7 of the MTSP is “to address the underlying social and economic determinants of health through policies and programmes that enhance health equity and integrate pro-poor, gender-responsive, and human rights-based approaches”. Implementation is addressed in specific objective 7.2 which focuses on the “initiative taken by WHO in providing opportunities and means for intersectoral collaboration at national and international levels to address social and economic determinants of health, including understanding and acting upon the public health implications of trade and trade agreements, and to encourage poverty-reduction and sustainable development”.
Further, in recognizing that support for the implementation of the SDHE agenda by national ministries of health will lead to an agenda that shares challenges with other agendas or initiatives, the meeting attempted to foster collaboration among actors from other fields. Within the ETH Department, the Right to Health agenda shares several of the same implementation challenges as other initiatives such as the PHC Renewal Initiative; the Noncommunicable Diseases, Poverty and Social Determinants Project; as well as the general health promotion agenda. From outside of WHO, the European DETERMINE project was also represented. DETERMINE – a non-governmental initiative that supports EU countries in implementing the SDHE agenda – is developing several knowledge products and tools to support countries in implementation.
Report scope and aims
Beyond acting as a detailed record of the meeting, this document also provides a summary of key background literature on implementation challenges produced during the life of the Commission. As such, the report aims to provide a more comprehensive overview of the potential challenges to implementing the SDHE than could be discussed within the confines of the meeting.
Framing the entry points for action
A framework for organizing the policy implementation knowledge base is shown below. The framework identifies two starting points for institutional change and two technical areas of competency. Institutional change can start within the health sector by making adjustments to the design of the health sector or to public health programmes. Change can also be initiated through engaging players from other ministries, with the role of the ministry of health varying from advocacy to leadership. In both cases,
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competencies are required by individuals and institutions in the technical areas of intersectoral action and social participation (see Figure 1).
Intersectoral action refers to actions undertaken by sectors outside the health sector, possibly (but not necessarily) in collaboration with the health sector on affecting health outcomes. Social participation can take on a number of different forms including (1) informing, whereby people are provided with balanced, objective information; (2) consulting, whereby the affected community provides feedback; (3) involving, or working directly with communities; (4) collaborating by partnering with affected communities in each aspect of the decision including the development of alternatives and the identification of solutions; and (5) empowering, by ensuring that communities retain ultimate control over the key decisions that affect their wellbeing.
Figure 1: Strategies for tackling the SDHE agenda
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Implementation challenges
The scope of the challenges was discussed at some length on the first day of the meeting. Summaries of presentations are available in the longer version of the report. The main challenges were defined as follows:
1. Political support: Often times, people in positions of power (i.e. politicians and policy-makers) fail to see the inherent connection between social factors and health. The problem is further exacerbated by the insufficient capacity of ministries of health, who also often do not find the issue of ‘health equity’ to be relevant. Nor do they, in fact, see the need for a population health approach such as presented by the SDHE agenda with an individual health-risk-oriented framework for action usually dominating. Where ministries of health are intent on tackling SDHE, they still experience difficulties in understanding other sectors’ agendas and how to “sell” the case for health equity and SDHE.
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2. Financing: The SDHE framework requires long-term investments that do not produce ‘quick
results’, making politicians reluctant from the outset. The need for quick returns is even more acute in low-resource economies. Finding out how to estimate costs and returns from SDHE investments is an important entry point to elaborating the role of health in overall development.
3. Providing “stewardship2” for organizational structures: Normally, health ministries occupy a relatively low station in the government cabinet, making it particularly difficult for them to garner adequate support and cooperation among other ministries to take action on SDHE. This impedes their ability to generate support for additional or alternative leadership structures or processes that would promote inter- or cross-sectoral action. This support is would be paramount to drawing attention to the impact on health equity of policies and actions across all ministries.
Tackling the SDHE agenda within the health system also presents a challenge in terms of defining the specific roles of new structures and processes needed to strengthen the health systems orientation towards the SDHE agenda, which could result in competition among the different actors. Further, it was noted that few ministries of health have structures or processes in place to promote social participation. The SDHE agenda may require new mechanisms or trainings to integrate social participation into the overall strategy.
Lastly, implementing the SDHE agenda will most likely require human resource capacity building (i.e. training) in order to ensure that all ministries of health are equipped with tools for dealing with new functions. This, however, does raise concerns for those ministries of health that are reluctant to receive guidance or adhere to a clear vision. In short, this lack of capacity in organizing the various governmental stakeholders (both within the ministries of health and across other ministries) in acting upon the SDHE agenda remains a major barrier to implementation.
4. Delivery options: The initiation of new services geared towards addressing SDHE or adjusting existing services may give rise to competition – or turf wars – among service providers. As such, integrating social participation into the service delivery process will be a major challenge and it will be crucial to find ways to transfer or share responsibilities as needed across ministries. It will also take considerable effort to ensure that user-groups participate in decision-making about service delivery.
5. Monitoring and evaluation: It has been noted that most ministries of health lack the capacity to undertake the monitoring of health equity and SDHE. To make matters worse, the data on health equity is usually sparse or altogether missing, and where it does exist, it lacks common measurement approaches and indicators. There is currently little guidance for ministries or governments on how to evaluate SDHE interventions.
WHO support to countries
Principles
2 Stewardship refers to the careful and responsible management of something entrusted to one’s care. In the context of health systems, it involves influencing policies and actions in all sectors that may affect the health of the population. The stewardship function therefore implies the ability to formulate strategic policy direction, while ensuring regulation and the tools for implementing it. However, the traditional function of many health ministries is to provide services, not stewardship. Their reorientation towards stewardship thus involves major organizational changes.
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Three principles were derived from the expert meeting to guide WHO’s actions in supporting countries to tackle the SDHE agenda. First, the SDHE agenda is not another programme, but rather a new way of conducting business. Second, WHO must acknowledge the bi-directional focus of all work on SDHE (i.e. collaboration within the health sector and with other sectors). At the organizational level, this means that an equity lens need be applied both within WHO and with respect to the organization’s relationship with countries and leading international organizations with mandates related to the determinants of health. Finally, supporting implementation at the country level requires core organizational leadership and action by WHO as a world health leader and as a technical partner on health at the country level.
Below is a summary of the 10 recommendations that came out of the expert group meeting grouped according to the three core organizational functions of WHO outlined above. A full account of each recommendation can be found in the body of the report.
Recommendations
(I) GLOBAL LEADERSHIP AND ADVOCACY
1. Improve the Organization's ability to and incentives for incorporating the social determinants for health equity approach across the house.
2. Advocate among the global health community, including UN agencies, donors, and countries on the importance of addressing the social determinants of health inequities
3. Promote global accountability on health equity and tackling SDHE.
(II) NORMS, STANDARDS AND GUIDANCE FOR COUNTRIES
4. Drive the global knowledge management, dissemination and communication processes related to the social determinants of health inequities agenda.
5. Develop materials and processes to guide and strengthen country capacities to implement the SDHE agenda.
6. Adopt an innovative approach for strengthening and drawing on expertise provided to WHO on SDHE.
7. Develop mechanisms for strengthening international collaborations on social determinants of health for health equity agenda.
(III) COUNTRY LEVEL SUPPORT
8. Support the inclusion of health equity and SDHE in national health plans.
9. Support the application of tools and the capacity development needed for the inclusion of the SDHE approach in the health sector.
10. Develop opportunities for intersectoral approaches and social participation in policy implementation.
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Focussing on less developed countries
In the course of their discussions of SDHE, members of the expert group addressed issues of health inequities among countries. They agreed that, as in other areas of its work, WHO should make a concerted effort to translate the SDHE agenda to fit the realities of less developed countries (LDCs) with a particular focus on Africa. In parallel, given the limited knowledge and number of countries leading the way in tackling health inequities, it was suggested that WHO capitalize on country leadership where it exists and provide all countries with an opportunity to participate in sharing experiences and learning how to translate the agenda into action.
Moving forward
The recommendations contained in this report describe a broad range of actions to be undertaken by a range of WHO actors from different teams within the ETH Department; WHO leadership; and various other departments in WHO and throughout the regions. In looking ahead and focussing on lessons learned for shaping the workplan of Strategic Objective 7.2, several priority areas for action were developed:
(1) Supporting the development of the “how-to” knowledge base and Organizational capacities;
(2) Supporting the generation of knowledge on how to apply the SDHE agenda in health systems and programmes and across sectors through whole-of-government approaches like Health in All Policies and in particular with the translation of this approach to middle and low-income settings;
(3) Supporting an expert group focussing specifically on implementation of the agenda in Africa;
(4) Joining other departments to develop problem-solving approaches and tools to deal with specific problems with strong intersectoral roots.
The existing budget and mandate of the ETH Department will permit modest advances on several of the recommendations in the 2008-2009 biennium. In fact, some progress has already been made and is being further developed in the context of existing directions of work. Realistically, trying to implement all the recommendations set forth by the expert group requires a broader organization-wide commitment to transformation. the feasibility of sustaining and amplifying WHO’s support to countries on this “transformation agenda” – whether under the banner of SDHE, PHC or some other label – will depend on the political commitment of Member States and providing the mandate to the Secretariat, as well as on making appropriate resources available .
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INTRODUCTION
WHO uses the MTSP to guide, inform and monitor its performance as implemented through departmental and programmatic workplans. The current medium term plan (2008-2013) is divided into 13 strategic areas, or Strategic Objectives (SO). One of them, SO7, prioritizes the mainstreaming of values and norms related to health equity, ethics and the right to health, while also addressing the broader determinants of health as a means of dealing with health inequities. Specifically, SO7 aims “to address the underlying social and economic determinants of health through policies and programmes that enhance health equity and integrate pro-poor, gender-responsive, and human rights-based approaches”. Within WHO headquarters, this area of work resides in the ETH Department, which is charged with coordinating the development of the workplan for SO7 within headquarters and assisting with coordination of work across regional offices.
Recently, WHO has demonstrated keener policy interests in helping countries address health equity by focusing on the actions of other sectors on health, namely the determinants of population health. In a keynote address at the WHO European Ministerial Conference on Health Systems in Tallinn (26 June 2008), the Director-General noted that “all countries are seeking ways to get other sectors to pay greater attention to the impact their activities have on health”. This function of health ministries is often referred to as “stewardship” for health.
On 2-3 June 2008, the ETH Department convened an expert meeting with support from the Regional Office focal points for SDHE to advise WHO on how to best support countries implementing the SDHE agenda. The meeting took place on the same day that the final draft of the report of the Commission was submitted to the WHO Director-General. In the same month, the World Health Report on revitalizing PHC was also due for completion. Both of these reports represent important policy think-pieces, putting health equity as a central goal and emphasizing the consideration of broader determinants as part of their strategy for making improvements to population health. It was therefore timely to gather and consolidate evidence on the practical challenges facing countries when translating the equity agenda into reality and how WHO could best support them.
The meeting was convened to assist the ETH Department in elaborating on its technical workplan for SO7.2, which is being implemented in the current biennium (2008-2009) and is being further developed for the next biennium (2010-2011). This objective focuses on the implementation of policies and actions tailored to achieve health equity with an emphasis on the intersectorality of health problems and their solutions. The department brought together experts to discuss the state of knowledge in the field and identify gaps in order to ensure a transparent, resource-efficient process for elaborating on its workplan.
Although the purpose of the meeting was not to look at implementation issues related specifically to the Commission recommendations, but rather to address implementation of the SDHE agenda more generally, the meeting was informed by several of the Commission materials. The Commission was launched in March 2005 and was designed to “collect, collate and synthesize global evidence on the social determinants of health and their impact on health inequity, and to make recommendations for action to address that inequity” (Commission Final Report, 2008). In other words, the Commission’s work focused on documenting how the broader social context affected population health and, in particular, health equity, including the role of health systems and programmes. This meeting used valuable background knowledge from several of the Commission and related WHO publications and processes.
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Meeting report
This report summarizes the preparations for, and discussions and outputs from, the meeting held in the beginning of June. It also summarizes lessons learned on the challenges involved in implementing an SDHE agenda globally. It presents recommendations from experts on how WHO can support countries in addressing implementation challenges. Experts invited to the June meeting were informed on the subject of implementation from a theoretical, and more importantly, a practical standpoint based on on-the-ground experiences in various countries.
This report aims to:
• inform general discussions on the challenges of implementing the SDHE agenda and related agendas around the world and on how WHO can best provide support;
• inform the development of the ETH Department’s SO7 workplan (specifically SO7.2) as well as assisting other teams in elaborating the workplans for other SO7 areas.
All efforts will be made to ensure that this report is widely distributed. It will be posted on the
WHO web (http://www.who.int/social_determinants/country_action/en/). It will be used to cultivate further discussions with partners and stakeholders on solving implementation challenges for countries taking action on SDHE. A wide range of participants developed background materials for the meeting, including critiques of their experiences in supporting country implementation and presentations of current country experiences, all of which are available on the WHO web site.
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BACKGROUND LITERATURE
Going into the June meeting, several pieces of literature were chosen as key focal points to inform discussions. They framed the development of the meeting agenda and discussion topics, in particular with respect to the identification of country-specific presentation topics and the group-work. The following key points were noted going into the meeting:
1. WHO developed a solid literature review for the Commission on core themes around which to centre implementation discussions. Two key themes were intersectoral action3 and social participation4.
2. However, the Commission did not explicitly systematize all of the gathered knowledge. The Commission country workstream identified the need for an explicit action plan derived as part of the implementation approach. The Measurement and Evidence Knowledge Network summarized the qualities of successful action and implementation plans.
3. The collaborative efforts between the Public Health Agency of Canada (PHAC) and WHO – implemented since 2006 to support the Commission – to study intersectoral action produced literature reviews and case studies on intersectoral action. Understanding the full range of roles that ministries of health can play across different contexts and providing appropriate support for these different roles emerged as a key theme for many countries. One of the conclusions of this work was that the health sector needs to acquire new skills that will allow it to contribute to wider societal goals rather than solely enforcing its own narrow targets.
4. Discussions of tackling the SDHE agenda with ministries of health frequently lead to the question of competing initiatives from WHO and other agencies. It also raises the question of where to start. Some ministries of health automatically assumed that the work should start outside the health sector. As a result, they have difficulties in seeing their role clearly. It was apparent going into the June meeting that SDHE communications needed to be clear on:
• how to relate to the health systems strengthening agenda and the PHC approach;
• the role of the ministries of health.
The Commission’s country workstream conceptualized the engagement of ministries of health with the SDHE agenda as either beginning with other ministries or with the health sector directly (system or programme design). The former was the more commonly accepted view by ministries of health in association with the term “intersectoral action”. Yet even working on orienting health systems and programmes to the SDHE agenda would require intersectoral action. Both strategies for tackling health equity also necessarily deal with the social causes of health inequities and associated power struggles to be resolved through enhancing social participation in policy development and implementation. Figure 1 provides a lens for assisting ministries of health in thinking through how to tackle the SDHE agenda.
3 Intersectoral action refers to actions undertaken by sectors outside the health sector, possibly (but not necessarily) in collaboration with the health sector on affecting health outcomes. 4 Social participation can take on a number of different forms including, but not limited to, (1) informing; (2) consulting; (3) involving; (4) collaborating; and (5) empowering. (See section above “Framing the entry points for action”.)
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Figure 1: Strategies for tackling the SDHE agenda
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The above points showed how the Commission pushed the boundaries of the knowledge base on implementation. Yet review of the Commission literature revealed large gaps in the scoping, systematic presentation and communication of implementation knowledge and uptake, in particular for the intersectoral-based agenda for health equity. The aim of scoping the implementation challenges set for the June meeting was proposed in order to build a more systematic view of implementation challenges. WHO systematization of work is still in the early stages. The discussions of this meeting were seen as providing a useful contribution for framing the implementation issues in a way that would provide a basis for the development of systematic guidance for WHO and Members States to support the translation of knowledge on interventions into practice.
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MEETING AGENDA AND PARTICIPANTS
Developing the agenda
Broadly speaking, the meeting agenda was developed by two key groups: WHO staff (including regional focal points) and national policy-advisers and policy-makers. Country experts had been previously identified during the Commission process. Several other public health experts also provided input. The meeting was chaired by Dr Don Matheson, former Deputy Director General of Public Health in New Zealand. Dr Matheson also served as rapporteur to the Policy Advisory Group, which was convened in 2007 to advise commissioners on how to maximize the impact of the recommendations made in their report in affecting health policy.
The main objectives of the meeting were to promote a discussion on implementation challenges facing different countries when translating this complex agenda into reality, in order to (1) gain greater clarity on the scope of practical implementation challenges and (2) outline the support needs of countries for meeting these challenges.
The development of the meeting agenda was an important process in and of itself. It was an opportunity to consolidate and summarize information on implementation challenges from a variety of documents from the Commission.5 It also brought together, for the first time, views from a wide range of WHO staff working to support the equity agenda in different parts of the organization. Short papers on implementation challenges prepared by WHO regional offices and several WHO programmes are available on the web site.
Participants
The expert group consisted of an even balance of staff from WHO, policy-makers from ministries of health and representatives of other international organizations. Internal WHO experts – aside from the ETH Department and SDHE focal points working in regional offices – included staff working to mainstream the health equity agenda across WHO, namely the health promotion team, representatives from the Priority Public Health Conditions Knowledge Network and the Kobe Centre. External experts included policy-makers and advisers from around the world; health policy academics; experts with technical skills on knowledge translation; and staff of other international organizations working to promote health equity (e.g. OECD, UNICEF and EC). Efforts were made to expand the group of country policy-makers in order to improve representation of LDCs. However, due to practical and logistical difficulties and limited resources, this effort did not yield the desired results.
5 In May 2006, WHO held a meeting on how the Commission and WHO could support countries directly through inter-country exchange and global advocacy. Similar consultations have been run regionally. One such meeting was held in Europe in December 2007. This technical consultation on Poverty and Health was held with 28 Member States and focussed on the discussion of case studies and papers. This meeting was also used to inform WHO’s strategy for in-country support in the region, including capacity building activities.
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MEETING DISCUSSIONS
Part 1: Framing SDHE Implementation Challenges
The implementation challenges countries are facing in adopting an agenda for tackling SDHE – as well as the type of support they will require from WHO – need to be seen in a broader context of competing agendas for political support. Asking countries to adhere to multiple agendas (in particular health systems strengthening, health promotion and PHC) can cause confusion and, ultimately, diminish support for an equity-oriented agenda. This topic formed the basis of the first part of the discussion at the meeting. Important points noted in presentations and during discussions include:
1. In communicating with policy-makers on SDHE issues, WHO must make a distinct connection between SDHE and other WHO agendas using clear, consistent language. Inconsistencies in SDHE-related language and terminology were found in several of the Commission’s and other WHO documents. Three specific problems emerged as a result of the SDHE discussions: (1) there are some misunderstandings on the relationship between social determinants of health and individual risk factors; (2) the terms “social determinants of health” and “health equity” are used interchangeably, despite the fact that they are separate, though interrelated, concepts; and (3) the discourse on proximal, distal, upstream and downstream determinants potentially conflates different, clearer concepts for understanding causality and appropriate interventions (namely levels, pathways and power).
2. A consultant suggested bridging this understanding by developing a framework made up of neutral categories such as: i) the main goal of the initiative; ii) the intellectual framework used to identify major determinants of health; and iii) the actionable approach (see Figure 3). WHO’s advice on implementation needs to describe an approach that is actionable by countries using the intellectual framework provided by the Commission.
Figure 2: A neutral framework for connecting different agenda’s: Kickbush I, “Synthesis Paper on a Global Overview of Country Needs and WHO Lessons and Plans for Supporting Countries”, 2008
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3. Links between SDHE, PHC, health promotion and health systems strengthening initiatives that are emerging on the WHO policy landscape were seen as centring on the following points:
3.1 the value of health equity (although less explicit in some understandings of health promotion);
3.2 the importance of social factors in determining health and health equity (although less explicit in the health systems frameworks).
4. The SDHE agenda should be a transformation to a new form of health governance rather than simply another programme.
Common to various WHO initiatives is the vision of a ‘transformation agenda’ both in the sense of health governance and health care delivery. With these different initiatives emerging at the same time, there appears to be a window of opportunity to make changes. New health governance will require health systems to grapple with new complexities and to work within networks rather than existing hierarchical structures. A transformative approach differs from an incremental agenda in the following ways:
4.1 It is value-based and communicated with passion.
4.2 It seeks out new ideas and identifies and responds to emerging trends in increasing social complexity, which requires new strategies such as working in networks, providing incentives for valuing relationships and people’s contributions and stressing capacity building.
4.3 Health is not just another social sector in the economy, but rather part of multiple sectors in global and national economies. As such, whole-of-government approaches like Health in All Policies are needed to address the broader socio-economic environment and the unsustainability of existing approaches that focus more narrowly on specific diseases.
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Part 2: Challenges and Support Needs of Countries Adopting the SDHE Agenda
At the meeting, experts presented a series of implementation challenges and support needs as well as lessons learned on overcoming challenges. These lessons were based on previous WHO experiences globally as well as on the perspectives of specific countries.
Based on WHO’s previous experiences with various countries across the world – as presented in short papers received from regional focal points and based on key programmes and initiatives6 – the scope of the implementation challenges faced by countries were outlined as follows:
• Health systems are an inherent part of the solution and introducing an SDHE approach implies a redistribution of power and resources, which will require long-term commitment and considerable strategic innovation. With many ministries of health experiencing difficulties in accepting the SDHE approach, WHO and other (inter)national actors will need to take on larger advocacy and leadership roles.
• Countries have expressed both the need for more evidence and concern for the lack of disaggregated national data. As such, the implementation of an SDHE agenda will require the improvement upon or development of national monitoring systems for health equity. An SDHE situation analysis may be an essential step in the implementation process.
• Countries have demanded more ‘how-to’ guidance (i.e. mechanisms, tools, strategies, capacities and skill-building trainings) to support them in implementing the SDHE approach. There is also an expressed need for knowledge-sharing and knowledge management in this new arena.
The following country implementers gave presentations on the SDHE agenda: • Canada: Working across sectors; • Chile: Mainstreaming SDHE within the health system; • Thailand: Social participation in health; • WHO Priority Public Health Conditions Knowledge Network (by Chairman Eric Blas):
Mainstreaming SDHE in health (outcome) programming.
The presentations addressed the following challenges: political support; financing; organizational structures; responsibilities and powers; delivery options; and monitoring and evaluation. These challenges are explained in the following pages.
It must be noted that these categories were only provisional and experts felt that there was some overlap between them. Nevertheless, they were considered sufficient and were used in the initial discussions, group work and plenary discussions following the presentations.
Political support
Arguing for values: In the end, health equity boils down to the issue of values. As such, it faces two major challenges. First off, it requires thorough public discussion, consultation and support. Second, there needs to be a comprehensive definition of the concrete actions that will result from adopting these 6 Extracted from the report commissioned by WHO from Kickbusch (2008).
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new values. In other words, there needs to be a clear picture of how things will be done differently. Experts indicated that a major challenge to the implementation of this agenda is that the public fails to see the link between social issues and health problems despite copious amounts of supporting evidence. This mentality can be followed all the way up to the top rungs of the political ladder as well.
As such, in order to garner the necessary societal and political support for SDHE action, it will be critical to make explicit the connection between social issues and health. Efforts must be made to inform people and policy-makers about existing evidence, current values and the potential implications of focussing on equity in the community. Strategies supporting a wider vision of health linked with determinants in the general public are the first essential step and should be part of any health reform process.
Health sector limitations: A number of capacity shortfalls within ministries of health can hinder political advocacy and undermine political support for an SDHE agenda. These capacity issues include:
• Inability to cope with (coordinate) multiple agendas; • Limited understanding of other sectors (and the public health knowledge base related to
determinants of health); • Low communication capacity beyond medical terminology, using terms from social
epidemiology and the political economy; • Limited understanding of the need to “compete” for resources within government and how to
“sell” the case; • Lack of leadership within the health sector (leader should be proactive, promotion-oriented,
flexible and supportive of other sectors’ goals and agendas).
The approach the health sector takes in its interactions with other sectors is critically important. The discussions were not in support of the approach to health care that implies that health is more important than other sectors and therefore is in the right to demand one-way support and resources. Quite the contrary: many participants saw this as health-centric and limiting, supporting instead the view that health should, in fact, reach out to support other sectors in order to achieving wider societal goals. In other words: it’s not about “what you can do for health”, but “what health can do for you”.
Limits across sectors: Often, other sectors don’t see their role in health and health equity in the community, giving rise to inter-sectoral opposition and conflicting messages.
The link between “good governance” and the socio-economic agenda needs to be analysed and better understood. It may vary across different parts of a country, particularly in developing countries, where issues of governance are connected to gaining political buy-in for the SDHE agenda.
The global context and WHO’s stance: Implementation happens within countries at the national, regional and local levels, but the global context and agenda are important for garnering political will.
Financing
Risk-aversion: SDHE strategies and interventions generally require long periods of investment before showing results, causing an increase in the political “risk” of investing in such strategies. In addition, the lack of evidence on the cost of health equity strategies – as they relate to the benefits – limits the ability of politicians to demonstrate short-term positive outcomes to voters.
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The competition for limited resources is especially critical in resource-poor settings and SDHE implementation is seen as being more costly without there being a clear indication of exactly what costs are entailed and how and when the benefits would be seen.
Health in development: There is generally a lack of appreciation for the broader role of health in a country’s development. In addition, donor fragmentation in low-income countries means that there is still much donor-dependency. Unless donors see a new role for health in development and provide financing, it will be difficult to implement this agenda in low-income countries.
Organizational structures, responsibilities and powers
Power Relations in the Central Government – The Cabinet: The lower standing of ministries of health in comparison with other governmental departments makes it difficult for them to get other sectors to consider their impacts on health. It seems that in order to ensure full implementation of the SDHE agenda, the cabinet must play a key role as the pivotal point of policy integration. However experts noted that even with the observed challenges, significant steps can be made through the health system and health programmes. The SDHE agenda can best be advanced through a variety of entry points – as circumstances allow – since “windows of opportunity” in the broader cabinet and health sector may be open at different times.
New infrastructure and institutions: There is reluctance about setting up new or “experimental” infrastructures without first establishing: mandates; implications of the new structures for the role of existing structures; a clear cost-analysis (budgetary considerations); and examples where similar structures have worked before (in similar settings). In general, existing boundaries and mandates would interfere with structures set up with more integrated, cross-reaching mandates. Experience shows that this may be easier to achieve at the local level than across national boundaries. However, the literature has revealed a lack of systematic evidence supporting intersecotral action in different contexts.
Different roles for health ministries: Knowledge and capacities within the health sector of how to act in different roles (e.g. advocacy, convening, monitoring) is limited.
Delivery options for intersectoral solutions
A key condition for addressing the social determinants of health was that potential actions be considered from an intersectoral perspective. Health is a by-product of different social conditions and several actors and sectors must be involved (eg. social affairs, education, infrastructure, employment, social protection and finance). In this context specific challenges include:
• If problems and solutions are identified on an intersectoral basis, it will always be critical to define who will be held ultimately accountable for ensuring service delivery.
• At the same time, in the context of multi-stakeholder processes, it is expected that there may be competition (or turf-wars) among potential implementers;
• Intersectoral collaboration is a field that lacks models of effective procedures and best practices on how to move from theory to actual delivery of services that address effectively social determinants of health;
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• At the same time intersectoral action also lacks models and enough systematized evidence on the appropriate financial and management coordinating mechanisms (e.g. between ministries).
Collaboration across social sectors – social participation
Various trust issues among civil society, governmental structures and other stakeholders in the private sector give rise to uncertainties regarding the appropriate processes and methods for ensuring participation of actors from the non-governmental sector. Collaboration is also hindered by the absence of formal methods for assessing capacities of potential partners across sectors.
Monitoring and Evaluation (M&E)
There is no common understanding – neither within health ministries nor in other sectors – on how to define and measure health and health equity. There is no appropriate, holistic definition of “health”, making it difficult to assess the success of an intervention in terms of social well-being and social goals.
The cost of equity and social determinants monitoring and evaluation systems has not been estimated or compared with the cost of other similar systems of governance (e.g. national health accounts, basic vital registries).
There is a lack of data, and even where data does exist, there is a lack of analysis in the area of equity. At the operational level, there are neither common indicators (qualitative or quantitative), nor agreed-upon equity stratifiers.
One of the most stifling difficulties in assessing the success of health equity programming is the cross-cutting nature of the interventions. In other words, the complex system of service delivery, involving a number of players from various fields, makes it difficult (if not impossible) to attribute credit to a specific entity or action for specific health successes. It becomes difficult to answer the question: Which actions by which sectors are contributing most to health impacts? This is of great political and practical significance and must be communicated effectively if other sectors are to recognize both their role in impacting health and the impact of health on their objectives.
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Annex 2: Meeting agenda and list of participants Part 3: WHO Support to Countries
Framing the Advice
The expert group developed three guiding, organizing principles in advising WHO on how to best provide support to countries striving to meet SDHE objectives.
Principle 1 – Transformation agenda
Recommendations were made with regards to ensuring that the SDHE agenda be implemented as a transformative agenda and not just as another programme. As such, they highlighted the need for innovation, recognizing network relationships and looking outside the health sector for examples of good practices.
Principle 2 – Bi-directional focus
All work undertaken by WHO on SDHE must be ‘bi-directional’, meaning it must work both within the health sector as well as in other sectors. At the organizational level, this means that an equity lens needs to be applied both within WHO as the leading international health organization and among other international organizations with mandates related to the determinants of health.
Principle 3 – Three spheres of simultaneous action
Experts came up with the following categories for WHO support to countries:
• Advocacy and leadership in creating a global, supportive environment; • The global function of producing norms and guidance materials; • More specific functions at the country level through country offices related to hands-on
technical support.
Although there is some overlap among these spheres (see Figure 3), experts felt it was useful to distinguish them in order to point out the political nature of this agenda. WHO clarity and leadership in this arena globally are pre-requisites for successful country implementation. Experts also perceived the need for a multi-level approach to implementation that will involve global, regional and national partners and players.
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Figure 3: Spheres of WHO Action/Support
Recommendations to WHO
(I) GLOBAL LEADERSHIP AND ADVOCACY
1. Improvements within WHO
1.1. Build conceptual clarity
Conceptual clarity is needed, both in theory and in terms of understanding the links between the SDHE agenda and PHC, health systems strengthening, health promotion, Health In All Policies and health impact assessments.
1.2. Build an organizational consensus position and appropriate institutional follow-up.
Use the Commission report, together with key policy think-pieces (i.e. World Health Report) on revitalizing PHC to engage WHO in broad-based discussions on its position on health equity and SDHE in the global health arena. Institutional follow-up should include:
• Review of WHO’s own policies and operations to see if the mainstreaming of an SDHE agenda has implications for its technical programmes, organizational structure or staff competencies. Are there any implications for the day-to-day work of individual staff, departments or the alignment of the governance process?
• Accountability: Develop a reporting system within WHO to track the mainstreaming of health equity and SDHE in programmes and consider ways of linking resources to this system.
• Technical substance: Pilot the SDHE approach in existing WHO programmes or initiatives and begin the technical process of defining what equity means in relation to each WHO programme. If the
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work is to be incremental, consider applying the “SDHE lens” in WHO high profile programmes or initiatives.
• Organizational structure and competencies: Build technical capacity across WHO, in particular with reference to those departments dealing with policy strategy.
• Funding: Ensure appropriate funding for the application of cross-cutting approaches of SDHE. Development of organizational competencies in this area will require focussed effort and a concomitant resource flow. Resources must readily follow any policy-level commitment by the organization if there is to be any meaningful transformation of the SDHE agenda into action.
2. Advocacy within and beyond the global health community
2.1. Have the loudest voice for health equity in the global community (as measured by independent authorities).
2.2. Consistently advocate for a broader health definition and a more comprehensive approach to tackling health inequities, specifically:
• Eradicating poverty; • Encouraging action and support to countries by development agencies (e.g. World Bank) and
donors to include an SDHE approach; • Engaging a network of institutions and collaboration within the UN system.
2.3. When the next major health challenge arises, make the SDHE approach an inherent part of WHO’s global response from the very beginning.
2.4. Convene intersectoral or ministerial meetings, where possible, to support collaborative action.
2.5. Mobilize resources for SDHE from donors when funding countries (including the World Bank).
3. Global accountability on health equity and SDHE.
3.1. Identify the appropriate global policy instrument for supporting this position and monitoring implementation from WHO.7 As a precursor, experts recommended the development of an action plan and strategy.
3.2. Include indicators for SDHE in existing UN accountability systems like the Millennium Development Goals (MDG) (a possible sub-goal under MDG 3).
3.3. Use international benchmarks with the aim of defining common indicators of inequity and success with reference to both medical and social science paradigms. Need to ensure use of comparable indicators across countries.
7 DGO Ian Smith’s presentation on “State-centred approaches to global health governance” highlighted the IOM Committee on the U.S. Commitment to Global Health Governance and Global Health, Washington D.C. (on 26 June 2008) and highlighted the emergence of “harder” global policy instruments being used in WHO over recent years (e.g. within WHO: Commissions (most mild), Regulations, Conventions, Treatments and Agreements (centre), World Health Assembly Strategies (most severe)).
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(II) NORMS, STANDARDS AND GUIDANCE FOR COUNTRIES
4. Drive the global knowledge management and communication process.
4.1. Develop communication strategies adapted to various cultural contexts.
• Commission follow-up should include, at minimum, support for the dissemination of the Commission’s products and key messages in regions, sub-regions and countries and the distillation of key messages, packaged into clear policy actions for countries.
• Particular attention should be given to developing messages for LDCs. Messages and materials must be adapted to different country contexts and needs. Promising story-lines include: the health and wealth dynamic; the health and global human development dynamic; and using human rights to promote health equity.
• Messages should appeal to a wide range of political beliefs and develop the argument for pursuing SDHE benefits in other sectors.
• Policy briefs must be developed to reach the political arena (at the regional and national levels) and should refer to the application of the SDHE approach to current issues falling outside the strict ambit of health. Consider issues such as MDGs, climate change, the food crisis, or, if within health, non-communicable diseases.
4.2. Support demand mobilization for SDHE knowledge through less conventional players such as civil society organizations (including those outside the health arena); global/regional/local media (using both facts and vivid examples); and the public (intolerance for inequities and forums for voices of marginalized members of society). Support alignment of these actors with government actions on SDHE.
4.3. Use an intersectoral approach in developing the knowledge agenda
• Help define the potential contribution of non-health entities to an equity agenda and vice-versa; • Develop partnerships to demonstrate the contribution of health to the goals and solution of problems in
other sectors; • Capitalize on alliances; • Develop tools to support dialogue with other sectors; • Find and build on examples of innovators in other sectors.
4.4. Promote evidence-based research.
• Promote research on SDHE through Bamako, knowledge network strengthening and think-tanks; • Identify evidence gaps and engage partners to fill them. One such evidence gap is in the area of costs
and benefits of SDHE strategies: more research must be conducted to provide authoritative evidence on this issue.
5. Develop tools/guidance for advancing the SDHE agenda and capacity building.
Ensure the relevance of tools to LDCs and indigenous peoples. Ensure linkages to existing WHO tools such as catastrophic health expenditure and national health accounts.
5.1. Tools to assist ministries of health in advancing the SDHE agenda within the health sector
• Mainstream equity, social justice and SDHE into specific programmes and policies;
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• Incorporate SDHE evidence and information into the daily work of health managers; • Identify, assess and prioritize SDHE needs; • Develop evaluation models and approaches to equity as a performance issue for health systems
(i.e. develop guidance on the inclusion of SDHE in health sector planning); • Assess and review delivery strategies and approaches (including other sectors).
5.2. Tools to assist ministries of health in advancing the SDHE agenda "outside the health sector" /with other ministries :
• Undertake stakeholder analyses and identify “movers and shakers”; • Evaluate social policies and their impact on health equity; • Develop process maps linking health and social inputs and outputs; • Hold dialogue with other sectors; • Develop models and frameworks for identifying and prioritizing SDHE interventions; • Develop models and frameworks including incentives for working across sectors; • Provide examples of framing legislation for more integrated policy-making (even if delivery is
organized by sector); • Determine how the health sector can contribute to other related strategies such as poverty
reduction and development plans (i.e. economic and human rights action plans).
5.3. Tools to assist ministries of health with monitoring and evaluation:
• Establish baselines and identify benchmarks and targets; • Develop multi-level monitoring and evaluation approaches drawing on existing information; • Ascribe changes in target variables to specific policy actions; • Develop frameworks for shared accountability and evaluation.
5.4. Tools to support capacity strengthening, particularly with respect to:
• Relating to other sectors and institutional competencies for collaborative action on SDHE; • Case building; • A shared language for SDHE for use by technical teams and policy implementers; • Monitoring and evaluation.
6. Adopt an innovative approach for drawing on SDHE expertise.
6.1. Conduct human resource mapping to identify capacities to facilitate work on health equity both in and outside WHO.
6.2. Develop a network of experts with innovative terms of references to support the mainstreaming and development of SDHE work within WHO. Issues to consider with respect to convening and identifying experts include:
• Breaking the mould of traditional WHO advisory groups focussed on a single speciality – the group should have a cross-sectoral focus;
• Ensuring an innovative profile of members (e.g. civil society, private sector, policy-makers, etc.);
• Ensuring experts are able to provide cross-regional learning;
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• Adopting a problem-based approach to convene experts around a specific social determinant important for health equity, as opposed to technical health programmes or even the broader topic of SDHE;
• Ensure that all materials and products produced by experts plan for resistance to change.
6.3. Ensure that technical expertise links to global social movements. Encourage the development of partnerships with movements, think-tanks and the private sector, where appropriate.
7. Develop mechanisms for strengthening country collaboration and sharing across networks. Enhance the meaningfulness of exchanges through stressing similar cultural and social contexts.
7.1. Support sharing of or access to:
• Case studies and lessons learned; • Synthesis of country experiences; • Innovative policies and strategies; • Models of successful networks, partnerships and delivery mechanisms.
7.2. Provide access to this information by:
• Developing mechanisms for sharing information, experiences and advocacy techniques; • Establishing or strengthening think-tanks and networks; • Conducting workshops, seminars, field visits and conferences.
(III) COUNTRY LEVEL SUPPORT
8. Support the inclusion of a health equity and SDHE approach in national health plans.
8.1. Support ministries in including health equity and the SDHE approach in the development and evaluation of national health plans as well as in their contributions to other national development plans and strategies.
8.2. Help ministries identify opportunities on a day-to-day basis for improving their collaborative efforts with both the health and non-health sectors.
9. Support the application of tools and capacity development.
9.1. Help ministries of health apply and adapt SDHE tools and guidelines.
9.2. Support the development of home-based SDHE evidence relevant to the local situation.
9.3. Support SDHE capacity development.
10. Develop opportunities for using intersectoral approaches and encourage social participation in policy development and implementation.
10.1. Support dialogue with other sectors by identifying topic entry points that target political concerns. Use specific partnerships, such as with health and agriculture, to work through the application of SDHE.
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10.2. Use the SDHE perspective to support health work in country-based UN activities.
10.3. Support platforms that give a voice to indigenous peoples and civil society.
Focussing on less developed countries (LDCs)
The group discussed inter-country health inequities and shared the view that WHO should pay particular attention to the translation of the SDHE agenda into the realities of LDCs. The expert group acknowledged the need for a parallel strategy of translation to LDC contexts while capitalizing on existing in-country leadership and to provide space for all countries. This parallel strategy was needed given the weakness of the implementation knowledge base for addressing SDHE.
With respect to LDCs, they called for special focus on Africa and stressed an approach that addressed LDC development and planning instruments like the MDGs, Poverty Reduction Strategies and national health sector planning instruments. Key messages with respect to LDCs were:
• Ensure messages and communication products relate to development agendas of LDCs (possible entry points include MDGs, health systems strengthening and governance);
• Target regional events or international events happening in Africa to discuss specific pieces of SDHE work (e.g. the next health promotion conference will take place in Africa);
• Ensure any WHO follow-up activities include a special strategy for LDCs;
• Advocate for the inclusion of SDHE-related considerations into the requirements of global donors (e.g. GAVI, Global Fund) and conduct specific fundraising activities for LDCs;
• Develop guidance and work with countries to include SDHE in their national health plans and target donors and processes to be aware of the SDHE approach (e.g. International Health Partnership and related initiatives).
The group noted the challenges of carrying out the SDHE agenda in LDCs, where the budget is very limited, and emphasized the need to ensure adequate funding.
Moving forward
The recommendations contained in this report describe a broad range of actions to be undertaken involving a variety of WHO actors from different teams within the ETH department, WHO leadership, and across WHO’s various departments and regions. In all instances, ETH actors need to coordinate their activities and focus on how to use the mandate of SO7 while managing limited resources most efficiently. These are ongoing features of departmental operational planning.
In looking ahead and focussing on lessons learned for shaping the workplan of SO7.2, three directions for future actions to improve WHO support were distilled. Some of these lines of action build on existing work, whose further development was facilitated by discussion within the department and with regional focal points and planning advisers the day following the meeting.
• Supporting the “how-to” knowledge base. Translating the evidence on SDHE interventions into practice requires equipping ministries of health with practical examples and methods for tackling the agenda – whether they frame their approach as working immediately across sectors or beginning from within the health sector and health programmes. For both entry points,
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knowing how to act intersectorally, including what models of governance and organizational oversight are appropriate, which tools can assist, and which capacities are essential in the process will be critical knowledge for ministries of health.
Facilitating the development of this practical knowledge base along with the tools and mechanisms to share this knowledge across countries should be further developed.
For follow-up in ETH, this requires two steps
a. Developing the intersectoral action knowledge base by building on the existing departmental work of the WHO - Public Health Agency Collaboration on intersectoral action.
b. Documenting and disseminating information on the range of tools being used and developed to support implementation of the SDHE agenda in countries, with a special focus on intersectoral action.
• Develop an overview of the range of tools currently available or being developed for supporting the social determinants for health equity (SDHE) agenda.
• Work with the WHO KOBE Centre and their Urban HEART project to identify opportunities for sharpening their tool's component that gathers knowledge on implementation, with particular reference to intersectoral action.
• Possibly focus the next expert resource group gathering on tools and priorities for tool development.
• As part of the continuation of the Priority Public Health Conditions (PPHC) knowledge network (KN), ensure that the collective experience gained by the PPHC knowledge network in their first phase is made available to countries engaging in reviewing their programmes with a SDHE lens and support the identification and documentation of other possible relevant tools through the PPHC-KN.
c. Support the development of a user-friendly, web-based process to maximize the on-going
sharing of country experiences.
• Supporting ministries of health in learning to apply the SDHE agenda and sharing between countries. Countries are kick-starting processes to translate the SDHE evidence and recommendations from the CSDH into action. WHO must also support these processes and ensure learning across countries in particular with respect to models of successful processes, institutional mechanisms for supporting intersectoral action and capacity development. Two types of processes are currently evident: (1) follow-up to the Priority Public Health Conditions Knowledge Network of the Commission, where ministries of health are applying an SDHE lens to the operation of the health sector and health programmes; (2) where ministries of health are applying whole-of-government approaches like Health in All Policies (with a particular look at translation to low and middle income settings). Some regional offices of WHO are also engaged in supporting other entry points for implementing the SDHE agenda. It will be important to distil learning from, and facilitate sharing and adaptation of these approaches in different settings.
• Less-developed Countries- Africa. With respect to action in LDCs, particularly in Africa, there is clearly a need for WHO to develop better mechanisms for translating messages and supporting action. A special group of advisers from Africa and African institutions convened to support the development of an Africa-specific strategy is a possible strategy to overcoming this problem.
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• Working on issues "outside the health sector" . There was a call for WHO to develop a way forward for operationalizing its approach to SDHE through addressing a technical problem at an inter-country and inter-ministerial level and to work on developing knowledge innovatively. A suggestion was to tackle a health problem that has obvious intersectoral implications and that affects other departments within WHO and focus knowledge assembly around that specific problem and its solution. (e.g. apply an SDHE lens to a problem like food, with the associated WHO department, and support the gathering of knowledge on implementation challenges and promising solutions with respect to the role of health).
Realistically, the existing budget and mandate of the ETH department and SO7.2 will only permit modest advance on several recommendations in the 2008-2009 biennium. Yet, by helping to sharpen the ETH workplan as described above, the experts have acted as a useful planning resource. The meeting was also used as platform for opening dialogue across the Secretariat and with partners across the Organization and outside with the aim to improve synchronicity in the Organization's work.
As discussed in the closing sessions of the meeting, action by WHO on the “transformation agenda” – including ETH’s role in the process – will require a broader, Organization-wide mandate. Following receipt of this mandate, and, given the current economic context, it is clear that ETH will need to prioritize the development of an effective fund-raising strategy that will aim to package a number of these excellent recommendations. Scaling up the size of investment in this area for the Organization will be key to establishing WHO's leadership in this area for the future.
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ANNEX 1: MEETING AGENDA AND LIST OF PARTICIPANTSDay One
8h30 – 9h00 Registration, coffee and croissants
9h00 – 9h30 1. Welcome and introductions
• Nick Drager and Nicole Valentine: meeting objectives and background • Don Matheson (Chair): participants and process
PART I MAPPING THE SCOPE OF CHALLENGES
9h30 – 10h30 2. Global assessment of countries’ implementation challenges and support needs
• Ilona Kickbush summarizes background papers from focal points (15 minutes)
• Plenary discussion (45 minutes) • Comments from two country representatives to start discussion
(5 minutes) • Palitha Abeykoon (Sri Lanka) on challenges for adjusting health outcome
programmes and using the primary health care approach • Fiona Adshead (UK) on health promotion and health systems
Background document: “Report on country needs for support in tackling health equity through social determinants and the WHO work, learnings and gaps” [document and presentation hard copies available at meeting; hard copies of original WHO inputs also available]
10h30 – 11h00 Break
11h00 – 12h00 3. The CSDH process and evidence for action at the country level
• Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health ‐ CSDH presentation by Sharon Friel (CSDH secretariat) (20 mins)
• World Health Assembly 2008: connecting the PHC and CSDH agendas (John Martin, 5 min)
• Plenary discussion (35 mins): What are the additional implications for country action and support needs from WHO?
Background document: “Health Equity at the Country Level: lessons from the CSDH on translating a complex agenda into action” [http://www.who.int/entity/social_determinants/country_action/en]
“Technical Advisory Group to Support the Translation of Recommendations by the WHO Commission on the Social Determinants of Health (CSDH) into Policy and Action at the Country Level” PowerPoint presentation. [http://www.who.int/entity/social_determinants/country_action/en]
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12h00 – 13h00 4. Country panel discussion on key support needs at different policy entry
points
• Input from panel: • Crossing sectors for health equity: Jim Ball (Canada) , comment by
Francisco Armada on additional issues for “local governance in urban settings” (WHO KOBE) (15 minutes) • Background document: “Health Equity Through Intersectoral Action:
An Analysis of 18 Country Case Studies ‐ Executive Summary” [http://www.who.int/entity/social_determinants/country_action/en]
• Improving participation for health equity: Ugrid Milintangkul (Thailand) (10 minutes)
• Mainstreaming health equity in health systems: Jeanette Vega (Chile) (10 minutes)
• Adjusting health outcome programme design Eric Blas (WHO) (10 minutes)
• Plenary discussion with panel (15 minutes)
13h00‐ 14h15 Lunch
14:15 ‐ 15:30 5. Country implementation challenges and support needs
Group discussion (1). 5/6 groups. Each considering:
• Advocacy for political support • Advocacy for financing for pro‐equity strategies and their
institutionalization • Negotiating the organizational structures, responsibilities and powers • Delivery options and tools to assist delivery • Monitoring and evaluation of the effectiveness of policies and tools to
assist
15h30 – 16h00 Break
16h00 – 17h00 6. Summarizing implementation challenges and prioritizing support needs
• Plenary discussion (30 minutes)after report back from 5/6 groups (5 minutes each)
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Day Two
PART II IDENTIFYING SUPPORT MODALITIES AND PRIORITIZING SUPPORT FROM WHO
8h30 – 9h00 Coffee
9h00 – 10h00 7. WHO support to countries for implementation
‐ Supportive global environment
‐ Technical support
• Broad‐based knowledge management for policy makers • Active learning and sharing learning on implementation • Expert advice to WHO and countries on implementation • Other? • Input • Broad‐based knowledge management for policy makers Clive Needle (5‐10
minutes) • The Active Learning modality Ilona Kickbusch presents a case study on an
active learning modality used in South Australian work on health in all policies (15 minutes)
• Expert advice to WHO Nick Drager (5‐10 minutes) • Plenary discussion (35 minutes)
Background document: Williams, C., Lawless A., Parkes H. 2008. The South Australian Health in All Policies Model: The developmental phase. Public Health Bulletin South Australia 5 (1) 30‐36. [www.health.sa.gov.au/pehs/publications/0803‐PHB‐HIAP‐vol5‐no1.pdf]
10h00 – 11h30 8. Recommendations to WHO on supporting countries
Group discussion (2). Participants will work in 5‐6 groups, making 10 recommendations to WHO on providing the following support to countries:
• Supportive global environment • Technical support
11h30 – 12h30 9. Report back from groups
• Each group reports back (5 minutes) • Plenary discussion (30 minutes)
12h30 – 14h00 Lunch
14h00 – 15h00 10. Prioritization of WHO support
• Presentation of consolidated list of recommendations • Plenary prioritization exercise
15h00 – 16h00 11. Summarizing outcomes of meeting and WHO next steps
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LIST OF PARTICIPANTS
COUNTRY REPRESENTATIVES José da Rocha Carvalheiro (Brazil) (Day 2) Vice Presidente de Pesquisa e Desenvolvimento
Tecnológico FIOCRUZ Av. Brasil, 4365 (Manguinhos) Castelo Mourisco,
sala 111 21045-900 Rio de Janeiro- RJ, Brazil Tel.: +55 21 3885 1617 Email: [email protected]
Mr Jim Ball (Canada) Director General Strategic Initiatives and Innovations Directorate Health Promotion and Chronic Disease
Prevention Branch 130 Colonnade Road, Ottawa, ON K1A 0K9,
Canada Tel.: (1) 613 941 6572
Email: [email protected] Dr Jeanette Vega (Chile) Undersecretary of Public Health
Huérfanos 1055 Of. 804 Santiago, Chile Tel.: +56 9 2346708 Email: [email protected]
Dr Hajime Inoue (Japan) Director, International Cooperation Office Ministry of Health, Labour and Welfare 1-2-2 Kasumigaseki, Chiyoda-ku Tokyo,
100-8916, Japan Tel: +81 3 3595 2404 Email: [email protected] Ms Teresa Wall (New Zealand) Deputy Director-General Maori Health Ministry of Health PO Box 5013, 1-3 The Terrace, Wellington, New
Zealand Tel.: 04 495 4393 Email: [email protected] Dr Tatiana Buzeti (Slovenia) Director Centre for Health and Development Arhitekta Novaka 2/b,. 9000 Murska Sobota,
Slovenia Tel: +38 625 30 2113
Email: [email protected] Dr Palitha Abeykoon (Sri Lanka) Special adviser to the Minister of Health and
Social Welfare 17 Horton Towers, Colombo c/o WR Sri Lanka
P.O. Box 780, Colombo 7, Sri Lanka Tel.: + 94 11 486 3620 Email: [email protected] Dr Ugrid Milintangkul (Thailand) Deputy Secretary-General of National Health
Commission Office The Ministry of Public Health Complex, Tiwanon
Road, Nonthaburi, 11000 Thailand. Tel.: +66-259 02308 Email: [email protected] Dr Fiona Adshead (United Kingdom) Director General of Health Improvement Department of Health Richmond House 79 Whitehall London SW1,
England Tel.: +44 20 797 25640 Email: [email protected] Mr Gunnar Ågren Director General Swedish National Institute of Public Health Olof Palmes gata SE-103 52 Stockholm Sweden
Tel.: +46 8 5661 35 00 Email: [email protected]
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TECHNICAL ADVISORS
Dr Don Matheson Chair 7, Lerwick Tce, Lyall Bay, Wellington,
New Zealand Tel.: +64 4 387 8062 Email: [email protected] Mrs Pascale Brudon Learning expert for WHO on the priority public
health conditions (PPHC) knowledge network (KN)
38, rue Carterets, 1202 Geneva, Switzerland Tel.: +41 22 344 5410 Email: [email protected] Michael De Looper Administrator/Analyst OECD Health Division 2, rue André-Pascal 75775 Paris Cedex 16,
France Tel: +33 1 45 24 76 41 Email: [email protected] Dr Mark Exworthy Reader in Public Management and Policy School of Management, Royal Holloway-
University of London Egham, Surrey TW20 OEX, United Kingdom
Tel.: +44 17 844 14186 Email: [email protected] Dr Sharon Friel Principal Researcher of the Commission on the
Social Determinants of Health Department of Epidemiology & Public Health
University College London Gower Street Campus 1-19 Torrington London
WC1E 6BT, United Kingdom Tel.: +44 20 767 98259 Email: [email protected] Mr Gordon Alexander Senior Advisor for Social and Economic Policy UNICEF Regional Office CEE/CIS Palais des Nations room 520 CH-1211 Geneva 10, Switzerland
Tel.: +41 22 909 5538 Email: [email protected]
Dr Kirsten Havemann Senior Advisor for Health DANIDA Ministry of Foreign Affairs of Denmark Asiatisk Plads 2, DK 1448 Copenhagen K,
Denmark Tel.: +45 33 920000 Email: [email protected] Dr Swantje Jäger-Lindemann Adviser European Commission Delegation Geneva - UN Section Tel.: +41 22 9182244 Email: [email protected] Dr Ilona Kickbusch International Public Health Expert Tiefental, Postfach 434 CH 3855 Brienz,
Switzerland Telf.: +41 33 951 0812 Email: [email protected] Dr Kimmo Leppo Former Director-General Health Department
Ministry of Social Affairs and Health, Finland Email: [email protected] Prof Helder Martins Professor of Public Health, Mozambique
Rua de França, 32 C.P. 3646 00310 - Maputo, Mozambique
Tel.: +258 21300780, Anx.: 280 Email: [email protected]] Clive Needle EuroHealthNet Rue Philippe le Bon 6, Brussels B-1000, Belgium Tel.: +32 2 235 03 20 Email: [email protected] Ms Carolyn Peterken Professional facilitator Mannet Consulting 7, Chemin du Rivage 1292 Chambesy,
Switzerland Tel.: +41 78 648 7647 Email: [email protected]
31
Charles Price European Commission Directorate-General for
Health and Consumer Protection Unit C4 Health Determinants
HITEC Building, Office HTC 01/168, L2920, Luxembourg
Tel.: +352 4301 33541 Email: [email protected]
Dr Orielle Solar Ministry of Health Chile and Adviser on the
Country Implementation Support Strategy (SUSEQ)
Mac-Iver 541 Santiago, Chile Tel.: +56 257 40100 Email: [email protected]
WHO/HQ SECRETARIAT
Dr Gauden Galea Health Promotion Tel.: +41 22 791 2582 Email: [email protected]
Ms Shawn Malarcher Preventing Unsafe Abortion Tel.: +41 22 791 3339 Email: [email protected]
Dr Kwok Cho Tang Health Promotion Tel.: +41 22 791 3299 Email: [email protected]
Dr John Martin PHC Agenda, DGO Tel.: +41 22 791 1498 Email: [email protected]
Dr Erik Blas Planning, Resource Coordination and
Performance Monitoring Tel.: +41 22 791 3784 Email: [email protected]
WHO/HQ SECRETARIAT: DEPARTMENT OF EQUITY, ETHICS, TRADE AND HUMAN RIGHTS
Dr Nick Drager Director Tel: +41 22 791 2789 Email: [email protected]
Mr Daniel Albrecht Tel: +41 22 791 1348 Email: [email protected]
Ms Helena Nygren-Krug Tel: +41 22 791 2523 Email: [email protected]
Ms Nuria Quiroz Tel.: +41 22 791 1415
Email: [email protected] Dr Kumanan Rasanathan (Day 1) Tel: +41 22 791 5457 Email: [email protected]
Ms Lina Reinders Tel.: +41 22 791 1828 Email: [email protected]
Dr Ritu Sadana Tel: +41 22 791 3250 Email: [email protected]
Mr Anand Sivasankara Kurup Tel: +41 22 791 1217 Email: [email protected]
Ms Nicole Valentine Tel: +41 22 791 3217 Email: [email protected]
Dr Eugenio Villar Montesinos Tel: +41 22 791 2616 Email: [email protected]
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Annex 2: Meeting agenda and list of participants WHO KOBE CENTRE Dr Francisco Armada Tel.: +81 78 230 3157 (Ext.84442) Email: [email protected] WHO REGION OFFICES AFRO Dr Benjamin Nganda Telf.: +47 241 39501Email: [email protected] EMRO Dr Sameen Siddiqi Telf.: +20 2 227 65306 Email: [email protected] EURO Ms Sarah Simpson Telf.: +39 41 279 2211 Email: [email protected] PAHO Dr Marco Akerman Tel.: +55 11 5576 9800Email: [email protected]
SEARO Dr Than Sein Tel.: +91 11 2337 0804 (Ext. 25437) Email: [email protected] Dr Davison Munodawafa Tel.: +91 11 2337 0804 (Ext. 26522) Email: [email protected] WPRO Mrs Anjana Bhushan Tel.: +63 2 528 9814 Email: [email protected]
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REFERENCES
Exworthy M, Blane D, & Marmot M (2003). Tackling Health Inequalities in the United Kingdom: The Progress and Pitfalls of Policy. Health Services Research, December, 38(6 Pt 2): 1905-1922.
Kickbusch I (2008). Synthesis Paper on a Global Overview of Country Needs and WHO Lessons and Plans for Supporting Countries. Draft.
Krieger N (2008). Proximal, Distal, and the Politics of Causation: What’s Level Got to Do With It? American Journal of Public Health, 98(2): 221-230.
Public Health Agency of Canada (PHAC) (2007). Crossing Sectors – Experiences in Intersectoral Action, Public Policy and Health. Prepared by the Public Health Agency of Canada in collaboration with the Health Systems Knowledge Network of the WHO Commission on Social Determinants of Health and the Regional Network for Equity in Health in East and Southern Africa (EQUINET) (http://www.phac-aspc.gc.ca/ publicat/2007/cro-sec/index_e.html).
WHO (2007). Everybody’s Business: Strengthening health systems to improve health outcomes. WHO’s framework for action, Geneva.
Figueras J, McKee M, Lessof S, Duran A & Menabde N (2007). Health systems, health and wealth: Assessing the case for investing in health systems. Copenhagen: WHO.
Stahl T, Wismar M, Ollila E, Lahtinen E, Leppo K, eds. (2006). Health in All Policies: prospects and potentials. Helsinki, Finland: Ministry of Social Affairs and Health and European Observatory on Health Systems and Policies.
Stahl T, Wismar M, Ollila E, Lahtinen E & Leppo K (2006). Health in All Policies in the European Union and its Member States. Policy Brief, Helsinki, Finland: Ministry of Social Affairs and Health and European Observatory on Health Systems and Policies.
Council of the European Union (2006). Council Conclusions on Health in All Policies (HiAP). Council meeting. Brussels, 30 November and 1 December 2006.
WHO Commission on Social Determinants of Health (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health, Geneva, WHO.
Van Herten LM, Reijneveld SA & Gunning-Schepers LJ (2001). Rationalising chances of success in intersectoral health policy-making. Journal of Epidemiology and Community Health, 55:342-347. (Available online at: http://jech.bmj.com/).
WHO (2006). The First Meeting of Country Partners: WHO Commission on Social Determinants of Health, Draft. Geneva, WHO.
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