Social determinants of health

We live in a much healthier world today. In the 20th century alone, life expectancy increased by 30 years as a result of major discoveries and improvements in public health, such as vaccination, injury prevention, access to clean water and safe food, and advances in maternal and child health.

The 21st century should work toward improving health further and making it equitable. Country life expectancies range from 82 in Japan to 34 years in Sierra Leone—an almost 50-year gap that no biological or genetic reason can explain.

In the Association of Southeast Asian Nations, life expectancy ranges from 81 in Singapore to 56 in Myanmar. The Philippines is somewhere in the middle, 71 for both sexes.

Inequities in health can also be noted within countries. For example, there is a 30-year gap in life expectancy between the most and least advantaged populations even in the rich city of Glasgow, Scotland.

In the Philippines, inequities among regions and income groups are glaring, spanning all known health indicators. For example, the most recent National Demographic and Health Survey showed that even if the national infant mortality rate was halved from 1990 to 2008, the rate in rural areas (35 per 1,000 infants) remained almost double that in urban areas (20 per 1,000).

Health is social

These health inequalities remind us that action is needed beyond medical interventions. Health, as defined by the World Health Organization (WHO), is the “complete state of physical, mental and social well-being,” but the “social” part is oftentimes the missing component in the equation.

Even as early as the 19th century, Rudolf Virchow, a German physician regarded as the father of “social medicine” and was a good friend of our national hero, Dr. Jose Rizal, asked: “Do we not always find the diseases of the populace traceable to defects in society?”

But it is not just the diseases themselves, but more so the unacceptable gaps in health that are products of a “toxic combination of poor social policies and programs, unfair economic arrangements and bad politics,” said the WHO Commission on Social Determinants of Health.

Social determinants of health refer to the conditions in which people are born, grow, live, work and age. They fall into two general categories: structural and intermediary determinants.

Structural, intermediary

Structural determinants generate stratification and divisions in society and define individual socioeconomic position within hierarchies of power, prestige and access to resources. They are embedded in key institutions and processes of the socioeconomic and political context. Examples include income, education, occupation, social class, gender and race.

Intermediary determinants are factors that directly shape individual health choices and outcomes and through which structural determinants operate. They span material circumstances, psychosocial circumstances, behavioral factors and the health system.

Examples include the nearby shop that sells cigarettes and alcohol, tensions among local leaders in a slum community, or the nonfunctioning rural health center that lacks essential medicines and health personnel.

For decades, the most successful public health interventions have dealt with intermediary determinants such as lifestyle changes and provision of food and medicine. However, global evidence now shows that structural determinants such as macroeconomic policies and cultural belief systems exert a huge influence on intermediary determinants and eventually widen inequalities.

WHO recommendations

Backed by substantial amount of evidence on global health inequities and their social determinants, the WHO commission came up with a set of recommendations on how to “close the gap in a generation,” the title of its 2008 report.

The three overarching recommendations were:

* Improve daily living conditions

* Tackle the inequitable distribution of power, money and resources

* Measure and understand the problem of health inequity, and assess the impact of action.

So what social determinants do we need to tackle in the Philippines?

PH situation

As emphasized by the commission’s report, daily living conditions need to be dramatically improved.

Rapid urbanization in Metro Manila, for example, has led to overcrowding, massive air pollution, garbage-clogging waterways, unsafe roads and growing squatter areas. Thirty-one percent of Filipinos in rural areas and 20 percent in cities have no access to improved

sanitation.

All these determinants bring about mental health problems, respiratory and diarrheal diseases, and road injuries, especially to vulnerable populations. They also worsen the human impact of natural disasters, as shown by the aftermath of Tropical Storm “Ondoy” in 2009, and cause greater disease burden on the local health system.

Employment

Although the Philippines claims to have reduced the unemployment rate to 7 percent last year, there remains a continuing trend of short-term employment. Contract workers suffer from low and unstable incomes and are vulnerable to unemployment in the long run.

The unemployed are more prone to catastrophic expenditures during an illness, have a reduced capacity to bring healthy food to the family table and ultimately suffer a much higher risk of premature death.

Finally, workers with no job security  or social protection are at high risk of mental and emotional stress, which may give rise to violence and dysfunctional families.

Lifestyle

Noncommunicable diseases such as hypertension, diabetes, cancer and chronic obstructive pulmonary disease account for 60 percent of adult deaths yearly.

Fortunately, these diseases are highly preventable through tackling intermediary determinants such as availability of healthy food in markets and stores, provision of open spaces to increase daily physical activity and stricter implementation of the provisions of the Tobacco Regulation Act.

Early childhood

Global evidence has shown that interventions in early childhood, from prenatal care to primary education, increase life expectancy and ensure lifelong well-being. Aside from improving access to maternal and child care in primary care facilities, health concepts must be explicitly included in primary education.

Education should also emphasize development of life skills needed for healthy and responsible living. The Department of Education should incorporate these reforms into its new K-12 program.

The intermediary determinants are also symptoms of deep-seated structural determinants and therefore both levels need to be addressed.

Governance

Governance in the country is characterized by factors detrimental to overall population health: lack of policy coherence and political will; weak accountability and implementation; corruption; lack of motivation and skills among government workers; and limited participation of citizens and civil society groups in decision-making, especially in health governance.

Peculiar to Philippine governance is the enormous clout of Catholic Church groups in influencing public and health policy, the best example of which is the reproductive health bill—a measure which seeks to reduce the inequities in access to maternal and reproductive health services.

Economic inequality breeds health inequities.  Ninety-percent of families belong to classes D and E, the lowest socioeconomic levels, according to a Pulse Asia survey in 2010.

It is established that further down the social ladder, more  diseases are common, access to health care is more difficult and ultimately, life expectancy is much shorter.

If we are serious in “closing the gap” in wealth and health, mechanisms that aim to redistribute wealth among various segments of Philippine society have to be put in place immediately.

Trade

In this era of increasing globalization, countries such as the Philippines actively participate in the crafting of bilateral and multilateral agreements and treaties. In 2011, for example, the Philippine government expressed interest in joining the Trans-Pacific Partnership and the larger Free Trade Area of the Asia Pacific during the summit of the Asia Pacific Economic Conference in Hawaii. Like previous trade agreements, these new instruments are expected to ease the flow of goods and services among member countries.

Certainly, these pacts will have a huge impact on the health of the people of member countries—directly through health products and services, and indirectly through food trade that will adversely affect farmers’ incomes.

To address these challenges, the WHO commission called for the institutionalization of “consideration of health and health-equity impact in national and international economic agreements and policy-making.”

Disaster-risk reduction

Our vulnerability to disasters may be partly due to unchangeable environmental determinants such as geography, but certainly much of that vulnerability has a social dimension—from the planning of our cities and towns to the implementation of the logging ban and early warning systems.

Furthermore, the Philippines, being the third most disaster-vulnerable and the sixth most climate-vulnerable country in the world, has to take climate change seriously, as it will worsen health conditions and exacerbate existing health disparities.

A “social determinants” understanding of disaster management and climate mitigation can prepare our society for the grave health impact, prevent the widening of social inequities and preclude us from solely blaming the forces of nature.

Elevating debate

Health is placed considerably high on the political agenda of the Aquino administration compared with the attention it received from previous administrations. In 2010, President Aquino committed in his first State of the Nation Address to achieve universal PhilHealth coverage by 2013.

The “Aquino health agenda” that was launched during the election campaign later metamorphosed into the Department of Health’s Kalusugang Pangkalahatan (Universal Health Care), which now looks into attaining the health-related Millennium Development Goals, public-private partnerships (PPPs) in health-facility enhancement and expanding PhilHealth coverage as ways to achieving health equity.

However, it is important that debates in health-care reform, particularly toward achieving universal health care, should be placed in the context of action on social determinants of health. Even the WHO commission report identified the health system as just one of the major determinants of health, so the discussion should not stop there.

US experience

Studies in the United States show that medical measures have contributed little in the decline of overall mortality. There are claims that health-sector interventions account for only 20 percent of health improvements, while the remaining 80 percent can be attributed to enhancements in daily living conditions—food, housing, clothing and access to socioeconomic services such as education and employment.

The Philippine health sector itself should adopt a social determinants framework, from the Department of Health to the various medical schools that train our future physicians.

The health department in particular should strengthen its stewardship role in advocating “whole-of-government” approaches to combating health inequities and addressing social determinants.

Australian model

A model that the Philippine government could use is the “health-in-all policies” approach. Pioneered in South Australia and now replicated in other countries, this government mechanism ensures that all government programs and policies, whether from the department of agriculture or foreign affairs, are assessed through a “health-lens analysis” of their impact on health outcomes and their contribution to reducing health inequities.

Coherence in governance results in policies and programs that complement each other to produce health and health equity. It is “unhealthy” to have, for example, an agriculture program providing assistance to tobacco farmers in tandem with a public health policy that bans use of tobacco products.

Never isolated

Furthermore, addressing the broader structural determinants is vital for the success of health sector reform. The health system is never isolated from the larger society, whose social determinants shape the structure and functioning of the health system. We need to look at how wage policies affect workers’ contributions to PhilHealth, or how bilateral trade agreements result in maldistribution and shortage of health workers in our communities.

Finally, the Philippine government should broaden the scope of public-private partnerships and include action on social determinants of health as a venue for collaboration. PPPs for health may go beyond from mere medical interventions and health-facility enhancement to building healthy cities and investing in social protection schemes. Private enterprises can also apply the social-determinants approach in protecting the health of their employees through internal reforms in business practices and employment policies.

Everyone a health worker

Ultimately, health is an outcome of the distribution of multiple determinants in a society, from the policies governing daily activity to the resources used to provide social services. The more these determinants are inequitably distributed, the sicker we become as a whole.

In the same way as society can make us sick, it can also bring good health, not just to some people, but to everyone—that is health equity. Making society conducive for health requires efforts, not just from the health sector, but from all segments of society.

There has to be a conscious declaration at the high-policy level that health is a universal-societal goal, not just a resource for economic progress and social development but an end in itself. Other sectors will then follow suit and strive to positively contribute toward achieving this end.

A Norwegian health minister once said, “Every minister is a health minister.” Everyone is a health worker when it comes to  acting on the social determinants of health.

(A final year medical student at the University of the Philippines Manila, Ramon Lorenzo Luis R. Guinto is the regional coordinator for the Asia Pacific of the International Federation of Medical Students’ Associations [IFMSA], a global network of 1.2 million medical students. He led the IFMSA delegation to the WHO World Conference on Social Determinants of Health in Rio de Janeiro, Brazil, on Oct. 19-21, 2011.)