Bringing different sectors together for addressing the social determinants of health: Education and Health

By Dr Luiz Augusto Galvão, & Dr Kira Fortune Pan American Health Organization/Regional office of the WHO 15 September, 2015

1 An Overall Panorama of Health Inequity in the Americas

2 PAHO’s Mission and Values: Equity, Social Determinants of Health and Health in all Policies

3 Health in All Policies, Equity and Education

4 Identifying Core Windows of Opportunities for Inter-sectoral Action

• At the close of the Millennium Development Goals, LAC has made significant progress

• The region has made strides in reducing extreme poverty, undernourishment and child mortality

• Life expectancy in the Region increased from 56 years in 1954 to 75 years in 2014

• The increase in average life expectancy largely reflects a substantial decline in under-five mortality rates

• Data from the Region positively reflect a low rate of child

malnutrition at around 4 percent and high immunization rate against measles at 93 percent

Source: ECLAC, 2013 and 2014

[1] An Overall Panorama of Health Inequity in the Americas

The Red Line between Washington, D.C. and Shady Grove, Md. has 17 metro stops spanning 30 miles and an estimated nine-year difference

in life span

• 2.2 billion people world-wide live on less than $2 per day

• Stark differences in economic opportunities

explain significant health inequities between and within countries

• There is a 32-year-gap in average female life expectancy between Mozambique and Japan

• The LAC regional ratio of maternal mortality per 100,000 live births is nearly ten times that of the European region, and less than one-tenth that of the African region

• Life expectancy in Dominican Republic is 73.5 whereas in Haiti it is 62.2 (a gap of 11.3 years within the same island)

Sources: Robert Wood Johnson Foundation, 2011

Sources: World Bank 2011; World Health Organization 2011 and 2014

Median income: $143,500

Median income: $58,526

[1] Inequity at a Glance

• Despite the fact that Latin America and the Caribbean is a middle income region, the Region is one of the most unequal region in the world with regards to income levels (PAHO, 2012)

• Recent evidence demonstrates that more than 1 in 4 residents of the Region lives in moderate

poverty (on less than US $4 a day) (World Bank, 2011)

• 28 million people in the Region live in extreme poverty (on less than US $1.25 a day) (World Bank, 2011)

• Currently 120 million people in the region of the Americas as a whole do not have access to health

services due to economic reasons (PAHO, 2009)

PAHO: Health in the Americas, 2012

poorer mid richer

1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

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10,000

15,000

20,000

25,000

30,000

35,000

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ome

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apita

($ p

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Income Growth by Income Terciles: Region of Americas 1980-2008

1

[1] The Greatest Challenges of the 21st Century: Poverty and Inequity

Key Challenges for the Region of the Americas: Non-Communicable Diseases, Urbanization and a Changing Epidemiological Profile

Health Systems

Family and Peer

Influences

Gender Norms

Social Exclusion

Ethnicity National Legal

and Policy Environment

Increased Urbanization

[1] Key Regional Challenges in the Americas

Employment

Cultural and Religious Values and Traditions

Source: ECLAC 2014; Figure 2 from Araujo et al/World Bank (2015) [white bars indicate one sample; grey bars two samples; black bars annual samples]

• Both access to and quality of education in the LAC region are strongly influenced by economic status

• In the lowest income quintile, 56% attend secondary school and 9% continue into tertiary

education, compared with 87% and 46% (respectively) for those in the highest income quintile • Educational outcomes are influenced by gender, ethnicity and other factors related to social

identity • School outcomes vary considerably, within the region and when compared with high-income

countries

Average out-of-school rate by household income within countries

[1] Inequality and Education in Latin America and the Caribbean

• PAHO is strongly committed to putting equity firmly on the agenda

• Equity and the Social Determinants of Health are key priorities in Health Agenda for the Americas 2008-2017

• Addressing inequities through the approach of the social determinants of health and Health in All Policies is one of the objectives in PAHO’s Strategic Plan 2014 – 2019

PAHO is an inter-governmental organization that consists of 38 Member States

[2] Mission in Action

Category 3: Determinants of Health and Promoting Health Throughout the Life Course

Outcomes Outcome Indicators

OCM 3.5 - Increased leadership of the health sector to address the social determinants of health and health promotion.

Number of countries implementing the Rio Political Declaration on the social determinants of health

Number of countries and territories integrating social determinants of health within their health sector programs

OPT 3.5.1 - Implementation of the WHO Health in All Policies Framework for National Action including intersectoral action and social participation to address the social determinants of health

Number of countries implementing the Health-In-All-Policies Framework for National Action

OPT 3.5.2 - Social determinants of health applied as a strategic approach in all PAHO Programs

Number of PAHO entities integrating social determinants of health in planning and monitoring processes.

OPT 3.5.3 - Countries enabled to generate equity profiles to address the social determinants of health

Number of countries and territories producing equity profiles addressing at least two social determinants of health

OPT 3.5.4 - Countries enabled to scale up local experiences using health promotion strategies to reduce health inequity and enhance community participation and empowerment

Number of countries implementing health promotion strategies to reduce health inequities and increase community participation

OPT 3.5.5 - Countries enabled to address Post 2015 Development Agenda on health responding to the social determinants of health.

Number of national consultations specifically addressing the Post 2015 Development Agenda on health.

[2] PAHO’S Strategic Plan: 2014-2019: Sustainable Development and Health Equity

Through public consultation, Member States identified Five Key Pillars:

A key outcome of the Global Conference was the Rio Political Declaration

Governance to tackle the root causes of

health inequities

Promoting participation

The role of the health

sector

Monitoring progress

[2] Rio Political Declaration Adopted by Member States, Sept 2011

Global action on social

determinants

Line of Action 1: Establish the need and priorities for HiAP

Number of countries and territories implementing the Health in All Policies Framework forCountry Action Baseline (2014): 6. Target (2019): 18.

Line of Action 2: Frame planned action

Number of countries and territories producing equity profiles that address at least two priority determinants of health at the national and sub-national level Baseline (2014): 1 Target (2019): 18.

Line of Action 4: Facilitate assessment and engagement

Number of countries and territories with mechanisms to engage communities and civil society in the policy development process across sectors. Baseline (2014): 9. Target (2019): 18.

Line of Action 6: Build capacity

Number of countries and territories with recognized institutes such as national public health institutes, universities and collaborating centers offering training courses on the implementation and monitoring of HiAP. Baseline (2014): 0. Target (2019): 8.

Line of Action 5: Ensure monitoring, evaluation, and reporting

Number of countries and territories that monitor, evaluate and report on progress towards introducing health and health equity in the development and implementation of government policies Baseline (2014): 0. Target (2019): 12.

Line of Action 3: Identify supportive structures and processes

Number of countries and territories with a specific mechanism, such as intersectoral committees or HIA, by which the health sector can engage within and beyond the public sector. Baseline (2014): 6. Target (2019): 18.

[2] First Regional Plan of Action on HiAP Adopted in September 2014

• White Paper highlighting state-of-the-art knowledge

in the Region of the Americas • Indicator Analysis to facilitate our work in

developing Roadmap including roles and responsibilities

• Roadmap to guide implementation of Plan of Action over the next five years

• Task Force and Working Group on HiAP and SDGs established

Expert Consultation on HiAP with wide range of experts defining next steps and concrete actions in implementing the Regional Plan of Action:

More than 65 experts involved in this Expert Consultation from the region of the Americas and beyond

[2] Putting PAHO’s Regional HiAP Plan of Action into Practice

2 Equality and personal protection have been a priorities of the Chilean administration. Creating a minimal state pension, it extended free social security and it created daycare centers for poor children, among some of their priorities. These efforts have put Chile in a good path to achieve the eight SDGs in 2015, and Chile was the only country in the region that achieved this prior 2015

Chile

With 15.5% of GDP, the total expenses of Costa Rica in the social sector social are the highest in Latinamerica. The average in LatinAmerica is 12.5 % (World Bank, 2007) Key investments have been made in health and education ensuring access to services for the whole population. Costa Rica has low levels of poverty and injustice , the highest life expectancy in the region and a significant level of social mobility.

Costa Rica

The percentage of the population living in poverty in 2001 was 37.5%. In 2009, poverty was reduced to 24.9%. It is estimated that the program Bolsa Familia, which emphasizes in health and education contributed to the decrease in 54% of poverty between 2001 and 2009 Brazil achieved its first SDG when it reduced the proportion of the population living in extreme poverty prior to the 2015 deadline

Brazil

[2] Examples of HiAP in the Americas

Measuring both education and health can tell us how well development is advancing the three pillars of sustainability (social, environmental and economic), particularly with respect to equity-related objectives. Seeking synergies between health and education has benefits for both sectors: healthier students are more likely to attend school consistently, and schools can act as central resources for health information, skills-building and services.

[3] Sustainable Development, Education and Equity

• Universal access to education is one of the most powerful determinants

of child well-being, health equity and development

• The Health Sector needs to continue strengthening its support for and work with education actors

• There are many entry points for health stakeholders to work with education stakeholders

Source: WHO, 2012

[3] Education and Health Are Closely Related

An opportunity to put a focus on:

• Sustainable Development • Health in All Policies • Equity • Social Determinants of Health • Education • Universal Health Coverage

[4] Moving Forward the Post-2015 Agenda

Sample of SDG Targets Involving Health, Education and Equity

By 2030, eliminate gender disparities in education & ensure equal access to all levels of education and vocational training for the vulnerable, including persons with disabilities,

indigenous peoples & children in vulnerable situations

Build and upgrade education facilities that are child, disability and gender sensitive and provide safe, non-violent, inclusive and effective learning environments for all

By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being

Support and strengthen the participation of local communities in improving water and sanitation management

Ensure universal access to sexual and reproductive health and reproductive rights

Image at bottom: Guttmacher Institute

[4] The Post-2015 Sustainable Development Goals Establish a Unique Opportunity to promote the Application of Health in All Policies

Networks

Evidence

Technical Cooperation

In line with the Regional Plan of Action of HiAP and the recent Expert Consultation on Health in All Policies, a series of opportunities exist: •HiAP training of trainers and HiAP training to be implemented in the Region of the Americas;

•Regional Review of Health Inequalities to be implemented in the Region of the Americas in collaboration with Michael Marmot’s Group;

•Document and show Case Studies on HiAP in the Region of the Americas;

•Developing equity profiles;

•SDG and HiAP Task Force established to oversee implementation of the HiAP Regional Plan of Action of HiAP and SDGs;

[4] Planned Activities and Opportunities

Image: National Institute for Health and Welfare; Finland

Regional Forum on Urban Health in Medellin in December 2015

UIPES Conference in Curitiba, Brazil in June 2016

WHO Global Conference on Health Promotion in Shanghai, China, September 2016

Health in All Policies Expert Consultation Washington DC 2015

[4] What Next: Bringing it All Together

THANK YOU