Determinantes sociales resucitando la agenda en Río...

In this guest post, Ted Schrecker offers a commentary on how the 2011 World Conference on Social Determinants of Health might restore an otherwise ailing SDOH agenda. Ted is an associate Professor in the University of Ottawa’s Department of Epidemiology and Community Medicine, and a principal scientist at the University’s Institute of Population Health.

The final report of the WHO Commission on Social Determinants of Health, published three years ago, should have represented a milestone in the quest to achieve the goal of Health for All articulated at Alma-Ata in 1978. Based on a synthesis of available evidence that was unprecedented in its scale, the Commission identified conditions of life and work that deny literally billions of people the opportunities for a long and healthful life as “the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics.” It went on to identify “changes in the functioning of the global economy” as critical to its objective of closing the health gaps between rich and poor in a generation. The Economist, in a generally laudatory review, said that the Commission was “baying at the moon.” Two months later, after a financial crisis had spread across the world, the Commission appeared remarkably prescient.

So what happened? Despite its heightened relevance post-2008, three years later the social determinants of health (SDH) agenda is in peril, although it could bring major benefits to the majority of the world’s population living in low- and middle-income countries (LMICs) and drive integration of health concerns into debates about how to distribute the pain of post-crisis austerity in high-income economies. The Commission may inadvertently have contributed to the problem by saying little about implementation beyond calling for a global social movement. Beset by budgetary constraints even more acute than usual, and by intense opposition to the agenda from elements of the medical profession both outside and (one suspects) within the organization, WHO is ill equipped to carry the agenda forward. The World Conference on Social Determinants of Health, to be held in Brazil in October 2011, appears directionless and sometimes seems nothing more than a ritual response to a generic World Health Assembly resolution responding to the Commission’s report .

The SDH agenda, and those who could benefit from its aggressive uptake, deserve better.  What to do?  The Global Fund to Fight HIV-AIDS, Tuberculosis and Malaria, now a decade old, provides a promising model. The Fund was established at the initiative of G7 governments convinced of the urgency of improving global health. They, the United States in particular, were also reluctant to commit billions of dollars for disbursement through UN system agencies that often were, and are, politics-driven rather than results-driven. The Global Fund is far from perfect; critiques of its emphasis on specific diseases rather than on strengthening health systems must be heeded. At the same time, the Fund has shown willingness to respond, and core elements of its organizational design – donor commitments of funds not tied to any specific project or beneficiary; independent scientific review; reliance on recipient-originated proposals as an indication of commitment; and rigorous auditing of both financial management and achievement of objectives – have survived the test of a decade well enough to deserve emulation.

Thus, a modest proposal for two initiatives to be taken forward by committed national governments at the October conference.

A Global Fund on Social Determinants of Health could be modeled closely on the existing Global Fund. It might more actively seek proposals from sub-national governments and civil society organizations in LMICs, subject only to assurance from the national government in question that it would not obstruct the initiatives for which funding was proposed. Proposals could range from pilot projects to national scale-ups of policies that had already demonstrated their effectiveness.  Funding criteria would give preference to policies and interventions that do not primarily involve health care providers and to support for intersectoral action.

A second fund, with a subtly different remit, could address governance issues central to SDH. This proposal recognizes the oft-neglected connections between SDH and broader issues of democratic governance (including governance of the global economic system), accountability, and human rights. For example, the annual value of illicit capital flight (a subset of the total) from sub-Saharan countries in the first decade of this century has been estimated at twice the value of the 2005 Gleneagles development assistance commitments, underscoring a major limitation of current initiatives to improve development assistance effectiveness. And the international human rights law framework offers important potential for reducing health inequity in areas ranging from access to essential medicines to protecting against forced evictions that benefit only a wealthy minority of domestic consumers and foreign investors. Thus, eligible proposals for purposes of this Fund might involve efforts as diverse as cross-border collaborations between civil society organizations and national or multilateral agencies to track and repatriate illicit flight capital, and provincial or local efforts to provide legal advocacy in support of economic and social rights.

These proposals are obviously presented in preliminary form, intended to stimulate further intensive discussion (and elicit better ideas) within a short time frame. Although the need for substantial new transfers to LMICs cannot be ignored, the two Funds proposed could probably be financed in their first few years with minimal new net expenditure by OECD development assistance providers, through redirecting part of the existing budgets of national aid agencies and major foundations.  In a “looking-glass world” of trillion dollar war budgets and bank bailouts, this argument is morally troubling.  Practically, making-do with existing resources would probably suffice to provide proof of concept; new commitments, whether by high-income countries with a history of innovation or by LMICs that have emerged as leaders in South-South cooperation, would strengthen the proposals from the start, and will be critical for longer term success. The challenge for the World Conference will be relentlessly to foreground the moral imperative of reducing health inequity, mobilizing resources that are abundant by any reasonable definition, while at the same time protecting the prospect of agreement on concrete proposals to restore momentum that has dissipated since 2008.