Prof. K. Srinath ReddyPresident,

Public Health Foundation of India

Overcoming Health Inequality ToAchieve Sustainable Prosperity

In The SDG Era

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SDGs

MDGsStrong Focus on MCH &Communicable Diseases

Higher Investment In Health

Strong Focus On

MCH

NCDs

CDs

UHC

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Health and DevelopmentThe 20th Century Discourse

Ø Critical importance of health as a productive resource and fillip fordevelopment recognized

Ø Increasing articulation of health as a human right

Ø Decline in many diseases occurred due to socio-economic/ public healthimprovements and preceded specific bio-medical interventions(Tuberculosis; other infectious diseases; coronary heart disease; stroke etc.)

Ø Advances in science and technology helped to improve health but havenot bridged gaps in health equity

Health Development

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Health And Development

Ø Influence the social, economic and cultural determinants ofhealth to enhance the gains in health and development.

Ø Health promotion and disease prevention through multi-sectoral action as the principal pathway for health ratherthan dependence on a purely biomedical clinical care andcure model – specially relevant to NCDs

Ø Ensure that Universal Health Coverage connects to SDH

Ø Position health in the framework of SustainableDevelopment, using SDH as the link

What is required in the 21st Century?

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FOUNDATIONS OF GLOBAL HEALTH

§ 20th Century: Shared Vulnerability

§ 21st Century: Shared Values

“Universal Is Local Without Walls’’- M. Torga

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Wide Disparities In Life Expectancy (Yrs.) - 2015

Japan Switzerland Bangladesh Rwanda Mozambique

LE 83.7 83.4 71.8 66.1 57.6

HLE 74.9 73.1 62.3 56.6 49.6LE = Life Expectancy At Birth

HLE= Healthy Life Expectancy

Source: Global Health Observatory data repository, WHO

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WHO: Urban HEART 2010

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§ Mortality is related more closely to relative incomewithin countries than to differences in absoluteincome between them

§ National mortality rates tend to be lowest incountries that have smaller income differences andthus have lower levels of relative deprivation

§ Most of the long term rise in life expectancy seemsunrelated to long term economic growth rates

§ Mortality is related more closely to relative incomewithin countries than to differences in absoluteincome between them

§ National mortality rates tend to be lowest incountries that have smaller income differences andthus have lower levels of relative deprivation

§ Most of the long term rise in life expectancy seemsunrelated to long term economic growth rates

The Spirit Level: Why More Equal Societies Almost Always Do Better (2009) by Kate Pickett and Richard Wilkinson

Unequal Societies Pay A Price In HealthClick t

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HEALTH EQUITYHEALTH EQUITY

§ Universal Health Coverage

- Financial Protection(Necessary But Not Sufficient)

§ Social Determinants of Health(Multi-Sectoral Action)

§ Empowered Communities(Rights Based Approach To Health)

§ Universal Health Coverage

- Financial Protection(Necessary But Not Sufficient)

§ Social Determinants of Health(Multi-Sectoral Action)

§ Empowered Communities(Rights Based Approach To Health)

“The future is already here — it’s just not very evenly distributed.”-William Gibson

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HEALTH EQUITY: PHILOSOPHICAL CONSTRUCT

• Utilitarian Justice

• Capability Right

Bentham

Rawls

Sen

“A well ordered society would ensure that all individualshave the capability to be healthy and at a level that iscommensurate with human dignity in the modern world,which is their right”

- Sridhar Venkatapuram. Health Justice; Polity (2011)

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Capability To Be Healthy

• Meta – Capability : an overarching capability to achievea cluster of basic capabilities -to be and do things that make up aminimally good human life in thecontemporary world

- (Sridhar Venkatapuram, 2011)

Includes multiple and diverseentitlements to goods, liberties,powers, privileges and immunities

- (Judith Jarvis Thomson, 1990)

• ‘Cluster’ Right :

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Equality of OpportunityOr

Equality of Social Circumstances?

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“Decorous Drapery”

With massive inequalities, where many are deniedan adequate education, unable to access effectivehealth care and housed in slums, “equality ofopportunity is nothing more than a cruel jest – theimpertinent courtesy of an invitation offered tounwelcome guests, in the certainty thatcircumstances will prevent them from accepting it”

- R.H. Tawney(Equality, 1931)

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What is required is not onlyan open road……. but an equal start

- R. H. Tawney(Equality, 1931)

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Social Determinants of Health (SDH)

Define Conditions Under Which

Individuals Can Get An Equal Start And

Run The Race Without Handicap

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SDH And ‘Capability For Health’:Extending Beyond Individuals

• Equity Among Communities

• Equity Among Countries

• Inter-Generational Equity

Ecological Public Health As The Unifying Framework

- (Rayner & Long, 2012)

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Low Birth WeightAnd Its Consequences

ReboundAdiposity

HypertensionCoronary heart

disease

Atherosclerosis,Stroke

Type II Diabetes,Insulin

resistance

Adult lungfunction

? Cancer

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Intergenerational Impact of Undernutrition

• Pregnant mother

• Girl Foetus in utero

• Oocytes of the foetus

Epigenetics Can Affect Three Generations !

During

One

Pregnancy

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HEALTH SYSTEM PEOPLE

SOCIALDETERMINANTS(OF HEALTH &NUTRITION)

Societal Personal

- Water - Income

- Sanitation - Education

- Food System - Occupation

- Environment - Social Status

- Social Stability - Gender

- Development - Networks

- Workforce

- Infrastructure

- Drugs, Vaccines & Technologies

- Financing

- Information Systems

- Governance

POLITICAL & ECONOMIC SYSTEM

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Universal Health Coverage iswhen ALL people receive thequality health services they

need without sufferingfinancial hardship

- WHO

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Health Beyond Health CareHealth Beyond Health Care

“ Health leaps out of Science and draws nourishmentfrom the totality of Society”

- Gunnar Myrdal(Swedish Economist, Nobel Laureate 1974)

POLICIES AND PROGRAMMES IN• Finance • Water • Sanitation • Agriculture • Food Processing• Education • Rural Development • Urban Design • Transport

• Communications • Trade • Environment

NEED TO BECOME SENSITIVE AND RESPONSIVE TOPUBLIC HEALTH CONCERNS !

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l Accelerating Progress on MDGsl Concerted Action To Control NCDs/CCIsl Implementing Universal Health Coveragel Promoting Social Determinants of Health

l Accelerating Progress on MDGsl Concerted Action To Control NCDs/CCIsl Implementing Universal Health Coveragel Promoting Social Determinants of Health

GOALS FOR GLOBAL HEALTH

Strong Health Systems+

Pro-Health Policies

Better Population Health Outcomes+

Improved Health Equity Indices

(As We Move Towards Post-2015 SDGs)

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Innovation As CatalystInnovation As Catalyst

§ Resource constraints can be overcome by innovation

§ LMICs can Drive Frugal Innovation

§ Innovations will be needed for- New Products- New Methods of Delivery- New Methods of Evaluation

§ Multi-disciplinarity and Real-World ConnectivityWill Be Critical For R&D

§ Resource constraints can be overcome by innovation

§ LMICs can Drive Frugal Innovation

§ Innovations will be needed for- New Products- New Methods of Delivery- New Methods of Evaluation

§ Multi-disciplinarity and Real-World ConnectivityWill Be Critical For R&D

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Sustainable ProsperitySustainable Prosperity§ Reduce Health Inequity

(Within And Across Countries)

Improved Population HealthHigher ProductivityLower Health Care Expenditure

§ Use Health As The SummativeIndicator of Success Across All SDGs

§ Reduce Health Inequity(Within And Across Countries)

Improved Population HealthHigher ProductivityLower Health Care Expenditure

§ Use Health As The SummativeIndicator of Success Across All SDGs

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POLITICAL AND ECONOMIC SYSTEM COMMITTED TOMULTI-DIMENSIONAL EQUITY & SUSTAINABLE DEVELOPMENT

EMPOWERED ANDENABLED PEOPLE

HEALTH SYSTEMCAPABLE OF DELIVERING UHC

SOCIAL DETERMINANTS OF HEALTH

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