Where we live, where we work, our education, our early childhood, our social power, our access to land and water: all these social determinants, and many more, affect our health.
This issue of Health Exchange focuses on the social determinants of health, what they mean for health workers and how we put this approach into practice. There are articles from a range of perspectives: the role of government in Sri Lanka, an NGO working at the grassroots in Kenya, an indigenous person’s view of holistic health in Nicaragua, early childhood development projects in Brazil, and community action in Sri Lanka. There is also an article discussing the work of the World Health Organization’s Commission on the Social Determinants of Health, which has spearheaded efforts to bring the approach to the forefront. Another contributor shares experience from a housing project in India’s urban slums.
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Social determinants have extremely powerful influences on health. The World Health Organization’s Commission on the Social Determinants of Health worked for several years to explore the global situation further. Ruth Bell, from University College London, talks about the work of the Commission and urges health workers at community level to call for action.
Health workers, more than anyone else, see the dramatic effects of the social determinants of health in their daily work. There is no biological reason why a girl born in Zambia should have a life expectancy of 43 years, while her counterpart born in Japan should have a life expectancy twice as long at 86 years. In a deprived part of Glasgow, Scotland life expectancy for men, at 54 years, is less than the average for men in India (62 years) where nearly 80 per cent of the population live on less than two dollars a day. Social determinants are linked to ill health and premature death witnessed by health workers wherever they are around the world.
As financial crises and shortfalls in health workers draw global attention, there is a possibility that we lose sight of a key resource for achieving our aspirations and rights in health – people! Rene Loewenson of the Training and Research Support Centre, Zimbabwe shows how interventions that empower communities in health lead to better health, but explains that we still have a way to go.
The living conditions of slum dwellers in Ahmedabad, India, have changed with new infrastructure projects, opportunities for employment and more social empowerment. Ultimately this has improved people’s health, and reduced their expenditure on medicines. This is how a social determinants of health approach works in action. Bijal Bhatt from Mahila Housing Self Employed Women’s Association (SEWA) Trust tells us more.
Early childhood development (ECD) is a key social determinant of health. In Brazil, public policies in favour of ECD are stronger than ever. Yet despite recent achievements, social inequality and poor children’s services are still major obstacles to the development of Brazilian children in their first years of life. Marcos Kisil tells how legal improvements alone are not enough: implementation is critical and there are already some good local examples at municipal level.
Community-led total sanitation at work
‘Healthy places, healthy people’ – is a phrase from the WHO Commission for the Social Determinants of Health and one which resonates strongly with development practitioners using community-led total sanitation (CLTS). CLTS is a grassroots approach to stimulate change in people’s sanitation behaviour through social action. Communities are taken through a participatory process. They realise their hygiene habits are unhealthy and decide to do something about it. Njoroge Kamau reports on the changes taking place in Kenya.
Sri Lanka is well known for having low infant and maternal mortality rates and prolonged life expectancy at birth while being a relatively poor country. There is now a better understanding of how the country achieves these remarkable health indices rapidly and consistently. Dr Saroj Jayasinghe and Dr Sarath Samarage report on how Sri Lanka is tackling the social determinants of health.
The Government’s strategy to deal with the social determinants of health consists of broad-based public interventions. For several decades Sri Lanka has provided universal health coverage free at the point of delivery. From the 1920s the country had a system of health units, where a health team led by a medical officer provided preventive services to a defined population
Community action on social determinants of health
The Sarvodaya Movement works at the grassroots to support communities to improve their own health. This is not health in a narrow sense. This is an approach that realises that education, employment, living conditions, cultural well-being and social empowerment play a crucial role in health. Vinya Ariyaratne, Executive Director of the Sarvodaya Movement, shares his experiences.
In the North Atlantic Autonomous Region of Nicaragua, the social determinants of health approach is not new to the indigenous people who live there. Their holistic and interconnected view of the world means they understand health at a community level, relating it with the access to land, to employment, to water and to leisure time. Florence Levy, from Health Unlimited talks about this perspective and the work she is doing to influence the Government to stop inappropriate vertical interventions.
Cardiovascular disease: combining research and action
Over 700 people living in Korogocho and Viwandani slums in Nairobi, Kenya have benefited from free drugs, regular screening and check-ups for heart disease, hypertension and other chronic conditions. Not what you might expect from a research institute, but this is how the African Population and Health Research Center (APHRC) is combining research and action. Elizabeth Kahurani and Rose Oronje tell the story.
The African Population and Health Research Center (APHRC) is spearheading efforts to ease the growing burden of chronic disease, especially among the urban poor. “Diseases that affect the heart and the blood circulation system, also known as cardiovascular diseases (CVD), are a leading cause of death and ill health in sub-Saharan Africa among adults aged 30 years and above,” said Dr Catherine Kyobutungi, an Associate Research Scientist at APHRC. [Read more →]