Social determinants of health

Stories of positive action from around the world

Story numbers correspond to those in the Report.

Health equity in all policies, systems and programmes

10.1: Intersectoral action on obesity

Obesity is becoming a real public health challenge in transitioning countries, as it already is in highincome nations. Obesity prevention and amelioration of existing levels require approaches that ensure an ecologically sustainable, adequate, and nutritious food supply; material security; a built habitat that lends itself to easy uptake of healthier food options and participation in both organized and unorganized physical activity; and a family, educational, and work environment that positively reinforces healthy living and empowers all individuals to make healthy choices. Very little of this action sits within the capabilities or responsibilities of the health sector.

Positive advances have been made between health and non-health sectors – for example, healthy urban living designed by urban planners and health professionals working together, and bans on advertisements for foods high in fats, sugars, and salt during television programmes aimed at children. However, a significant challenge remains: to engage with the multiple sectors outside health in areas such as trade, agriculture, employment, and education, areas in which action must take place if we are to redress the global obesity epidemic. Source: Friel, Chopra & Satcher, 2007

10.8: Health impact assessment of the London health strategy

In 2000, the London Health Commission (LHC) was established as an independent commission by the Mayor as part of the implementation of the first London Health Strategy. Its overall aim was to reduce health inequities in the capital and to improve the health and well-being of all Londoners by raising awareness of health inequities and promoting coordinated action to improve the determinants of health across London. The LHC achieves its goals through influencing key policy-makers and practitioners, supporting local action, and driving on specific priority issues through joint programmes. The LHC has completed HIAs on all of the mayoral statutory strategies and some of the non-statutory strategies.

The general approach to these has been the following: establishing a steering group; screening and scoping of draft strategy; rapid appraisal of evidence; policy appraisal stakeholder workshop; reporting recommendations to mayor; recommendations into final strategies; monitoring and evaluation; publishing evidence reviews and HIA reports. An independent evaluation showed that the LHC’s HIAs were making a difference to London’s strategies and the approach is cost effective. HIAs increased stakeholder awareness of the impact of their wider policies on health. This prompted earlier consideration of health in strategy development and contributed to the further development of HIA methods and tools and the evidence base. Source: NHS, 2000

10.10: Active involvement of the affected community – sex workers in Kolkata

In the early 1990s, the All India Institute of Hygiene and Public Health (AIIHPH) initiated a conventional STI treatment and prevention programme in a redlight district in north Kolkata. The Sonagachi HIV/ AIDS International Project (SHIP) was implemented through an intersectoral partnership of WHO, AIIHPH, the British Council, and a number of ministries and local NGOs. Sex workers in the area were poor and marginalized. The project quickly moved beyond traditional treatment and education modalities to focus on the empowerment of the sex workers. Key interventions during the first five years included vaccination and treatment services for the sex workers’ children, literacy classes for the women, political activism and advocacy, micro-credit schemes, and cultural programmes.

The sex workers created their own membership organization, the Durbar Mahila Samanwaya Committee (DMSC), that successfully negotiated for better treatment by madams, landlords, and local authorities. In 1999, the DMSC took over management of SHIP, and has since expanded to include 40 red-light districts across West Bengal. It has an active membership of 2000 sex workers and has established a financial cooperative. The strong occupational health focus and the emphasis on giving sex workers more control over their bodies and living and working conditions has resulted in low rates of HIV infection and STIs in Sonagachi relative to the rest of the country. Source: WHO & PHAC, 2007

10.11: The Gerbangmas movement in Lumajang district in Indonesia – a revival of primary health care within the new economic context of Indonesia

Following the principles of primary health care as expressed in the Alma Ata Declaration, in 1986 Indonesia launched the integrated health posts (Posyandus). While these achieved impressive coverage, with 254 154 Posyandus operating in 2004, the quality and general performance is varied and has deteriorated considerably. One contributing reason has been drop-out of the health volunteers associated with economic and ideological transition, reducing voluntarism, and collectivism. To redress the situation, the District Health Office initiated and spearheaded a mechanism to coordinate multisectoral interventions to rejuvenate community health development. It mobilized support from the highest political authority in the district and enrolled an NGO as partner.

In January 2005, the elected head of Lumajang district launched GERBANGMAS as a strategy of community empowerment and the local government defined three functions of the Posyandus: community education, community empowerment, and community service. The multisectoral village GERBANGMAS teams are provided with a general budget allocation from the local government, which is matched by the community and used for activities as well as to provide incentives for health workers. To guide investment and development, 21 indicators have been defined. Only about one third of these are traditional health indicators, such as use of family planning. The rest address determinants of health, including poverty reduction, literacy, waste management, housing, and mobilization of youth and the elderly. One proof of the functioning of the village team is that 12 sectoral bodies, including fisheries, public works, labour and transmigration, agriculture, and religious offices, provide budget support through the village team. All indicators have improved, both the health-specific and the upstream determinants of health. Source: PPHCKN, 2007c