1. New Life for Primary Health Care: the Social Determinants of Health Dr. Mirta Roses Periago PAHO/WHO WHO Commission on the Social Determinants of Health Presentation to the WHO Commission on the Social Determinants of Health Vancouver, Canada June 2007

2. 220 million people living in poverty The Americas is the most unequal region of the World: 220 million people living in poverty The Region is characterized by a demographic transition with high population growth, and rapid and unplanned urbanization. Research has shown the complex relationships between the social, economic, environmental, political and culture conditions – known as the social determinants of health – in the health of the population and communities. The Social Determinants of Health in the Americas

3. New focus on the SDH and human development recognizes that health should be central to the development agenda because: –Health is a basic human need –It is indispensable in the establishment of democratic societies –It is a fundamental human right Any approach to improve health should be linked within a broader economic, social and political context, and should allow for the inclusion of multiple actors and sectors The Social Determinants of Health (SDH) and Primary Health Care (PHC)

4. Achievements of PHC in the Americas include: For the past 30 years, PHC has been recognized worldwide as a key component of effective health systems. 1970 Lalonde Report establishing the concept of the “non-medical” determinants of health. 1980 “Health for All;” expansion of PHC and vertical programs in selected countries; SILOS; renewal of community participation. 1990 Establishment of the concepts of sustainable human development; health sector reforms; elimination of polio in the Americas. 2000 Commission on Macroeconomics and Health; focus on equity in health; MDGs; WHO Commission on the Social Determinants of Health.

5. Primary Health Care in the Region of the Americas –Need to address exclusion in issues related to health. –Need to broaden social protection as a central element of sectoral reforms. –Definition of new strategic and programmatic orientations to improve health outcomes. –Integrate and incorporate the Millennium Development Goals (MDG) There are still challenges and inequities to overcome in the countries of the Americas

6. The Social Determinants of Health and Primary Health Care equitable health and human development health systems PHC is a useful approach for equitable health and human development since it requires that more attention is placed on the operational and structural needs of health systems (access, sustainability of resources, political commitment, guarantee of high quality care, etc.).

7. Right to the highest attainable level of health Equity Solidarity Responsiveness to peoples’ health needs Quality-oriented Governmentaccountability Social justice Sustainability Participation Intersectoriality First Contact Comprehensive, integrated and continuing care Family and communitybased Emphasis on promotion and prevention Appropriatecare Activeparticipationmechanisms Sound policy, legal & institutional framework Pro-equitypolicies & programs Optimalorganization & management Appropriatehumanresources Adequate and Sustainableresources Intersectorialactions Universalcoverage and access Core Values, Principles and Elements in a PHC-Based Health System

8. PAHO understands PHC as an integral part of the development of health systems and that the most appropriate path to produce equitable and sustainable improvements in the health of the people of the Americas is to build health systems based on PHC. PAHO Technical Cooperation in PHC

9. 1.Responsiveness to people’s health needs 2.Government accountability 3.Quality-oriented services 4.Social justice Main PHC Principles for Technical Cooperation

10. 5.Sustainability 6.Intersectoriality 7.Social and individual participation Main PHC Principles for Technical Cooperation

11. In the past few years, the Region has faced considerable changes: Rapid and unplanned urbanization Structural changes in health systems Climate changes Demographic transitions Increased inequity and poverty In the Americas, the principles of PHC have been adopted and adapted by each country according to its own reality and needs. Social and Environmental Aspects of Primary Health Care

12. The emphasis on the environmental aspects of PHC has been highlighted with the definition of “primary environmental care” (Borrini, 1990) that includes a focus on community-based development to achieve sustainable lifestyles with 3 elements: Fulfill basic human needs Strengthen people and community Optimal and sustainable use and management of community resources Social and Environmental Aspects of Primary Health Care

13. One of the most effective answers is to consider PHC in its most broader form, emphasizing health promotion and prevention, as well as active citizen and community participation to achieve better health. Social and Environmental Aspects of Primary Health Care

14. The initiative analyzes local realities, develops critical interventions, and provides targeted technical assistance with the support of PAHO/WHO technical units and other UN system agencies. Communities are chosen by national Ministers of Health in collaboration with PAHO/WHO Representatives (PWRs). Selection is based on their extreme conditions of vulnerability and poverty. To date there are in 26 communities in 13 countries participating. Is designed to foster a citizenry that exercises its capacity for change through their collective and individual power. It is a catalyst for change, that coordinates actions to allow political leaders, the leaders and inhabitants of the communities, NGOs, IOs, and the international cooperation community work together at the local level. Reviews the experiences of work done since Alma Ata and re- energizes them through local work with a concrete objective; advancing towards the MDGs. This initiative’s contribution to the Region is to shift from the analysis of MDG indicators to participatory, action-oriented research that fosters local empowerment. Puts the emphasis on improving conditions of peoples and their territories through the community self-management model. Empowers individuals and the community via a horizontal exchange partnership between local communities and providers of technical assistance. Faces, Voices, and Places of the MDGs is a regional initiative that targets the poorest and most vulnerable communities in Latin America and the Caribbean to help them achieve the MDGs from the perspective of health. Active Selected Movement Community "Our greatest concern must always rest with disadvantaged and vulnerable groups. These groups are often hidden, live in remote rural areas or shantytowns and have little political voice." Dr Margaret Chan WHO Director-General

15. WHO Commission on Social Determinants of Health / Knowledge Networks and Faces, Voices and Places Social Exclusion The initiative is aimed at addressing the most vulnerable, neglected and economically deprived communities. In Ventanilla, Peru, through participatory action research methodology exercises the community and its citizens are being empowered to reduced social exclusion. Measurement and Evidence The initiative’s initial diagnosis includes a thorough study of available data on the community, setting of baselines and targeting and monitoring of advances. Through the PAHO - CEPAL-CELADE Agreement, census data from 19 LAC countries was analyzed and sub-national poverty maps were created to facilitate targeting of the most vulnerable communities. Women and Gender Equity In the Chiquimula and El Estor regions of Guatemala multi-cultural and gender perspectives have driven the work. This will lead to the development of healthy mechanisms, processes and actions to be taken at the local level to reduce gender-based inequities in health. Priority Public Health Conditions In Santa Fe de Veraguas in Panama, malaria control has been approached with a focus on socially and economically disadvantaged groups. Interventions and actions to improve the situation will address the social determinants causing inequities in health outcomes, barriers and will facilitate access to health care. Urban Settings In four communities in the Greater San Salvador area in El Salvador work is underway to address the most vulnerable and marginalized communities. The strategy employs an intersectorial, multi-programmatic, approach to influence health determinants through participatory activities centered on situation analysis. Early Child Development In Yuty, Caazapa, Paraguay, efforts involving the community component of the IMCI strategy are underway through participatory planning exercises with local leaders. These have led to disease prevention and health promotion activities under MDGs 1, 4 and 5. These provide opportunities to young children and their mothers in shaping sound lifelong health and development status.