Social determinants of health

Stories of positive action from around the world

Story numbers correspond to those in the Report.

Political empowerment - inclusion and voice

14.1: Identity and rights in Bolivia

Of Bolivia’s population, 55% is of Quechua or Aymara origin. It is estimated that nearly 9 out of 10 people in Bolivia’s rural and indigenous communities do not possess identity cards, while more than half do not have the birth certificates needed to acquire one. Without a birth certificate, children cannot go to school – closing off a potential escape route from poverty. Without an identity card, people cannot vote, have limited legal rights, and are effectively excluded from accessing social and health services.

These services include Bolivia’s national health insurance for mothers and pregnant women, which was introduced to combat the country’s high maternal and child mortality rates and yet is closed to women who cannot produce their identity cards. Through the Right to Identity project, the United Kingdom DFID is working with Bolivia’s National Electoral Court, nongovernmental organizations, and communities to make it easier for people to register and receive their identity cards and to raise awareness of their rights as citizens. Source: DFID, 2008

14.2: Indian legislative support for women

Through the Indian national parliament, the 73rd Amendment to the Indian Constitution, enacted in 1993, legislated that one third of village council seats be for women. This is considered one of the strongest reform measures to change the pre-existing norm whereby women had very little representation in political bodies. Women’s organizations have been active in training elected women. There are over 1 million elected women representatives on village councils, exercising authority over budgets and setting local policy priorities. Source: Indian Government, 1992

14.4: Ugandan constitution and citizen's participation

Uganda now actively encourages participation in health decision-making. The Constitution underlines the importance of, “active participation of all citizens at all levels” and civil society organizations have been involved in the preparation of Uganda’s Poverty Eradication Action Plan. Uganda has a new policy of decentralization in the health sector. Within district health systems, there are four levels of organization and administration, the lowest being Village Health Teams, also known as Village Health Committees. From the right-to-health perspective, these Village Health Teams play a pivotal role in providing grassroots community participation in the health sector. Source: Hunt, 2006

14.9: Legal support for community empowerment - SEWA, India

Like other poor self-employed women, the vegetable sellers of Ahmedabad, India, live in poor conditions. The Self-Employed Women's Association, SEWA, a union of almost 1 million workers, is an example of collective action by these women to challenge and change these conditions. Frequently harassed by local authorities, the vegetable sellers campaigned with SEWA to strengthen their status through formal recognition in the form of licences and identity cards and representation on the urban boards that govern market activities and urban development. That campaign, started within Gujarat, subsequently went all the way to the Supreme Court of India. To strengthen control over their livelihoods, all SEWA members linked together to set up their own wholesale vegetable shop, cutting out exploitative middlemen.

SEWA also organizes childcare, running centres for infants and young children, and campaigns at the state and national level for childcare as an entitlement for all women workers. Further, SEWA members are improving their living conditions through slum upgrading programmes to provide basic infrastructure. This happens in partnerships with government, civil society organizations, and the corporate sector. In order to solve the problem of access to credit, the SEWA Bank provides small loans and banking facilities to poor self-employed women. The bank is owned by its members, and its policies are formulated by an elected board of women workers. Source: SEWA Bank, nd

14.12: Taking action on rights and trade: the case of AIDS medicines

“The human right to health requires the provision of essential medicines as a core duty that cannot be traded for private property interests or domestic economic growth. This right may provide a means of achieving a more public health-oriented formulation, implementation and interpretation of trade rules by domestic courts, governments and the WTO alike. The growing power of this right is similarly reflected in an emerging jurisprudence where medicines have been successfully claimed under human rights protections”. A decade ago, the high cost of AIDS medicines led WHO and UNAIDS to advise that treatment was not a wise use of resources in poorer countries. Prevention of HIV/AIDS was preferred over treatment.

There was no international funding for developing countries to purchase drugs and companies gave extremely limited price concessions. A dramatic battle for AIDS medicines ensued that peaked in 2001 in the Pharmaceutical Manufacturer’s Association case in South Africa. Between 1997 and 2001, the United States and 40 pharmaceutical companies used trade pressures and litigation to prevent the South African government from passing legislation to access affordable medicines. Industry claimed that the legislation (and the parallel importing it authorized) breached TRIPS and South Africa’s Constitution and threatened industry’s incentive to innovate new medicines. The pharmaceutical companies went to court in South Africa. An extraordinary level of public action accompanied the case, attracting global censure against the corporations. In April 2001, the pharmaceutical companies withdrew their case. A norm cascade followed, with a sharp upsurge at the UN in international statements on treatment as a human right and articulations of state obligations on antiretroviral therapy. The same year saw the WTO issue its Declaration on TRIPS and Public Health.

These rhetorical commitments were matched by considerable policy and price shifts. Antiretroviral therapy prices in many low-income countries dropped from US$ 15 000 to US$ 148-549 per annum. New global funding mechanisms were created, such as the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, the United States PEPFAR and the World Bank Multi-Country HIV/AIDS Program for Africa. In 2002, WHO adopted the activist goal of placing 3 million people on antiretroviral therapy and, in late 2005, shifted upwards to the goal of achieving universal access to treatment by 2010, a goal similarly adopted by the UN General Assembly and by the G8. In 5 years, access to antiretroviral therapy in sub-Saharan Africa has increased from under 1% to current levels of 28%. Source: Forman, 2007