Chilean social protection system for early childhood:
Chile grows along with you
Francisca Infante and Helia Molina
Early childhood provides a unique opportunity for achieving neurological, biological and social milestones that are critical for future development. Achieving these milestones require a fostering environment that promotes development. Where children are born, live and learn directly affects the life chances and health they will have in the future, the skills they will develop, the education they will access, and the occupational opportunities they will have. Francisca Infante and Helia Molina share some experiences from Chile.
A child born in a poor neighborhood in Chile is more likely to have developmental delays, less years of education, do poorly in school, and subsequently as an adult is likely have a low income, high fertility at an earlier age, and provide poor health care, nutrition, and stimulation to his/her own children, contributing to the intergenerational transmission of disadvantage. Thus early childhood is considered a social determinant on its own, providing developmental opportunities that are not repeated in later moments of the life cycle, which will allow girls and boys to have access to better opportunities later on. At the same time it is affected by other social determinants of health. Evidence shows that assuring equal opportunities for the development of children and families allows social and economic development, as well as reducing inequity.
Community Led Total Sanitation: the process
The following describes the process used in Community Led Total Sanitation (CLTS).
Pre-triggering activities
The facilitator(s) identify a village with low sanitation coverage and one which has favourable conditions for triggering CLTS. The facilitator enters the village through local leadership, which could consist of village elders, government representatives like chiefs (in Kenya) and opinion leaders. The leaders organise a meeting with the entire community (social mobilisation).
Social Map
The facilitator meets the community at the agreed venue, e.g. a village shopping centre or open public space. S/he introduces her/himself as someone who is interested in learning more about the village – its geographical layout; social profile; resources etc. It is important that s/he does not give impression that s/he is an expert out to educate the community, but rather like a student out to learn from the community.
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Social empowerment as a determinant of health
As financial crisis 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 tells us more.
The Commission on the Social Determinants of Health has echoed at global level the point made in many prior reports – people have a central role to play in achieving better health (WHO CSDH 2008). This isn’t a new perspective. ‘Community involvement in health’ (CIH) has been recognised as a critical dimension of health systems for many decades. The 1976 Alma Ata declaration made participation a central feature of primary health care. The 1987 World Health Organization (WHO) Harare declaration proposed reorientation of political and health systems to support such participation. Perhaps what is now being more clearly stated is that making sustainable gains in health and in the effective allocation of resources for health is as much about power as about method. One aspect of this is peoples’ power to decide on actions and direct resources for health and to challenge those contexts, interests and processes that block this. Nina Wallerstein (1992) describes this social empowerment as ‘people’s ability to act through collective participation by strengthening their organisational capacities, challenging power inequities and achieving outcomes on many reciprocal levels in different domains: including psychological empowerment, household relations,… transformed institutions, greater access to resources, open governance and increasingly equitable community conditions’ .
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Social determinants of health: what do we do now?
The summer 2009 issue of Health Exchange focuses on the social determinants of health, what they mean for health workers and how we put this into practice. To mark the issue Healthlink Worldwide, Merlin and RedR hosted a lunchtime discussion in London, UK. Participants, mainly from NGOs working in health and development, discussed social justice, equity and the social determinants of health. They talked about what it looks like for development NGOs to be involved in the social determinants of health approach; and don’t NGOs always put equity at the forefront of their work? What is different now?
Alison Dunn, of Healthlink Worldwide writes about the discussion. [Read more →]
Health Equity: to the centre of the global health agenda?
Kumanan Rasanathan, Eugenio Villar Montesinos, Department of Ethics, Equity, Trade and Human Rights, World Health Organization, Geneva.
A concern for health equity is not new in global health. Equity was central to the World Health Organization (WHO) 1946 constitution, and to the work that culminated in the Declaration of Alma Ata in 1978. Despite this, the health agenda has mostly focused on securing progress on priority challenges. This has contributed to substantial advances in average life expectancy in most parts of the world. Yet the global health community has often seemed unable to counter the widening inequities brought by uneven progress.
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The summer 2009 issue of Health Exchange http://healthexchangenews.com focuses on the social determinants of health, what they mean for health workers and how we put this into practice. To mark the issue Healthlink Worldwide, Merlin and RedR hosted a lunchtime discussion in London, UK. Participants, mainly from NGOs working in health and development, discussed social justice, equity and the social determinants of health. They talked about what it looks like for development NGOs to be involved in the social determinants of health approach; and don’t NGOs always put equity at the forefront of their work? What is different now? Alison Dunn, of Healthlink Worldwide writes about the discussion.
Can we do more to improve health equity? In May 2009, 193 member states of the World Health Organization (WHO) approved a resolution calling for action to achieve health equity at the 62nd World Health Assembly.
The resolution was based on the recommendations of a 2008 report by WHO’s Commission on the Social Determinants of Health- Closing the gap in a generation: health equity through action on the social determinants of health.
Ruth Bell, Senior Research Fellow from University College London, who wrote an article for this issue of Health Exchange, presented the work of the WHO Commission on the Social Determinants of Health. Ruth was a researcher on the secretariat of the Commission, compiling and synthesising data about social determinants of health from all over the world. She presented how the Commission worked, and why it focused on health equity. There is no biological reason why life expectancy is 40 in some places and 80 in others and why there is huge discrepancy in health and well-being within and between countries.
Looking at the social determinants of health raises some serious questions for health systems and health workers. It can be very frustrating to treat people’s illnesses and then send them back to the conditions that made them sick in the first place. Ruth highlighted an example from Rene Loewenson’s article in Health Exchange on social empowerment as a determinant of health, where a mother took her five-year-old-daughter to a clinic to be treated for diarrhoea. The clinicians said to give her food and lots of water, but the mother only had access to water twice a week. Daily living conditions prevented her daughter from receiving the treatment she needed and she died.
The Commission calls for three principal areas of action: tackle the daily living conditions in which people are born, grow, live, work and age; tackle the structural drivers of those conditions at global, national and local levels; and carry out more research to measure the problem, evaluate action and increase awareness. In trying to address structural drivers of conditions, the Commission queried the efficacy and power of the market to solve all the problems.
Ruth pointed out that while the social determinants of health approach is having a resurgence, it is not new. The concept was first on the global agenda at Alma Ata in 1978, where the Declaration stated that wider determinants are very important. She talked about how colleagues working with the Commission started calling it, unofficially, the ‘Equity’ commission and saw it as an opportunity to re-introduce equity and fairness onto the global health agenda.
Part of the approach is to bring sectors together to work to address health at global, national and local levels., “It is the job of people working in health to say to others, working in education or employment for example, that what you are doing is also very important for health,” Ruth said.
One participant posed the problem that if health is everything to do with development, and everything we do is health, it can lead to a cul-de-sac. Another asked whether the Commission felt it was ideologically linked with left wing politics because of its findings and how did it deal with this. Ruth responded that the social determinants of health approach is about equity and social justice and has not been perceived to be about political ideology. She cited Michael Marmot, Chair of the Commission, who said that social justice and equity seem to be having a resurgence in influence globally. WHO’s work has been very high profile and UNESCO’s recent work on education has a strong focus on equity..
The WHO Commission’s report makes recommendations for action by a diverse range of stakeholders. As some participants at the discussion said, data can be ammunition. Dr Lee Jong-Wook, the late Director General of WHO, said in 2004, at the start of the Commission’s work, “The goal is not an academic exercise, but to marshal scientific evidence as a lever for policy change — aiming toward practical uptake among policymakers and stakeholders in countries”.
