19 May 2005Global Partner Country Consultation WorkshopCommission on Social Determinants of Health

Proposal and Design of the Knowledge Network for Public Health Conditions

A Social Determinants Approach to Priority Public Health Programs

WHO Geneva

• Rationale: Why a knowledge network on

public health conditions as part of the CSDH agenda?

• Proposed Approach: process and focus of activities

• Proposed Products and Deliverables: to support public health programs within countries

Presentation covers

• Rationale: Why a knowledge network on public health conditions as part of the CSDH agenda?

• Proposed Approach: process and focus of activities

• Proposed Products and Deliverables: to support public health programs within countries

Discussion

• Comments and suggestions, including areas and mechanisms for engagement with CSDH country work stream

Presentation covers

Risk and Treatment Disparities in Tuberculosis, Kenya 2003

0

10

20

30

40

50

60

70

80

% of patients

surveyed

Expected Cases Rx Completion

Poor

Non Poor

Adapted from Hanson et al 2003

Tuberculosis Treatment Disparities, Kenya

lowlowlowlow

highhighhighhigh

Visits to providers

highhighhighhigh

highhighhighhigh

Patient Adherence

80%80%80%80%lowlowlowlowlowlowlowlowhighhighhighhigh98%98%98%98%Least Poor

4444

20%20%20%20%highhighhighhighhighhighhighhighlowlowlowlow98%98%98%98%Poorest

Least Poor:PoorestRatio

Actual Effectiven

ess

Cost of Care

Diagnostic delay

Case detection

Expected Efficacy

DOTS for Rx of Smear +ve

TB

Sources of disparities

More equitable service provision requires action on the social determinants of health

Adapted from data from Hanson et al 2003 and from framework of Peter Tugwell

Because priority public health control programs at international and national level have resources that can be leveraged and reshaped towards improving equity; examples exist on how to do so; share, learn from and build on

A. Rationale: Why is this important and important now?

Because health systems architecture and programs design are core business

of WHO

Because health systems –disease control programs

are themselves social determinants of health

Why the Health System is a social determinant of

health ?

• HS reflects and exacerbates existing patterns of

social inequality (inequitable access, differential

consequences); and

• provides a site from which to contest the underlying

power differentials and decrease inequities.

Priority public health control programs can be leveraged and reshaped towards improving equity

A. Rationale: Why is this important and important now?

Effectiveness Coverage:

effective services to all in

need – universal coverage

Contact Coverage

Acceptability Coverage

Accessibility Coverage

Availability Coverage

Tanahashi 1978 Total or Target Population

Identification and implementation to "scale up" each

type of coverage –with social

determinants & equity lens

Towards population impactTowards population impactTowards population impactTowards population impact

Population effectiveness =

Intervention efficacy x

Intervention availability x

Diagnostic accuracy x

Provider compliance x

Patient compliance x

Coverage

Source: Multi-country evaluation data applied to Tugwell Framework

Towards effectiveness coverage: example of Integrated Management of Childhood Illnesses in Tanzania

Intervention efficacy 65%

Health workers are trained 80%

Health workers assess child correctly 63%

Health workers treat child correctly 65%

Coverage (mother recognised illness,

sought care and complied with treatment:

child receives the intervention)

40%

Pneumonia mortality averted = 9%

Expectation: Reshape Strategies & Actions at different levels

Example responsesAreas of Actions

Better international alignmentV. Global level

Support MoH to better contribute to sector-wide strategies from SD and pro-health equity perspectives

IV. Public policies cutting across sectors

Reshape national program guidelines, approaches to report social determinants, equity and health

III. Health sector policy and strategic management level

Improve design of programs to increase access & effective services; o support integration of national programs reach of vulnerable groups

II. Health services delivery level

Developing equity enhancing demand strengthening strategies, informing & meeting expectations of vulnerable communities

I. Community and household level

• Review factors in design and implementation of programs that increase/decrease access and effective services to socially/economically disadvantaged groups

• Identify entry points at different levels of HS and intersectoral actions

- Estimate expected change in overall and group-specific prevalence for selected conditions if improved case management of disease and inequities in access are addressed

B. Approach: Proposed objectivesProposed objectives

Process

• Towards consensus - systematic framework to measure & report on health inequities using conceptual framework of the CSDH, guidelines from the Measurement/Evaluation KN and Health Systems KN, and act

• Facilitate wide range of priority public health programs to go beyond recognition of inequity in process and outcome, towards a strategy to decrease inequity and unfair differences: prevent, expand access, increase case detection & cure rates

• Recognize that desirable actions can differ for different diseases and contexts – etiology, epidemiology, interaction of biological and social pathways

• Criteria for priority public health programs to be included: 1. mix of important diseases in terms of mortality, morbidity,

disability and other consequences of disease in low/middle income countries

2. selection from communicable, non-communicable, with important risks or social determinants, over life course

3. where successful experience exists

Potential Priority Public Health Programs and other network members

• HIV/AIDS• TB• Depression• Gender based

violence• Road traffic injuries• Diabetes• Tobacco, Obesity• Maternal Mortality• Indoor air pollution• Others

Focus

• Template on analysis, policy, program and monitoring/ evaluation in order to:

1. describe social pattern of disease

2. identify social patterns in related risk factors

3. review factors in design and implementation of programs that increase or decrease access and effective services to socially/economically disadvantaged groups

4. identify entry points for programs to reduce health inequities via (a) health policies, (b) specific health system and program actions and (c) intersectoral actions

• Produce & disseminate concrete products during CSDH and beyond

C. Proposed Products and DeliverablesProposed Products and Deliverables

1. Review of recent WHO guidelines from equity and social determinants perspectives

2. Update WHO guidelines on guidelines including equity and social determinants criteria

3. Reshape WHO guidelines in 3-5 priority program areas4. Indicators & methods to assess equity, in access, treatment, etc.5. Detailed background papers, shorter manuscripts for peer-review

publications, and policy briefs6. Synthesis - 1-2 topics in collaboration, such as

- relevance to resource-poor and instable contexts- differential barriers/facilitators for prevention, case detection &

treatment7. Report to Commission

• raise awareness for distributive justice and equity in HIV/AIDS

•equity indicators for monitoring and evaluation of policies

• advocate for special care to ensure access for the most vulnerable, poor and marginalized populations and for women.

• process of setting priorities and policies should include people living with HIV.

• Road crash injury is a social equity issue – equal protection to all road users should be aimed for since non-motor vehicle users bear a disproportionate share of road injury and risk

• Road crash victims are vulnerableroad users such as pedestrians and cyclists who benefit least from policies designed for motorizedtravel, but bear a disproportionate share of the disadvantages of motorization in terms of injury,pollution and the separation of communities.

• Concrete guidelines for national policy makers and planners to develop a policy response

• Initiating policy development process

•Formulating policies

•Seeking approval and endorsement

Road Traffic injuriesBurnsDrowningYouth Violence

• What is poverty

• How are poverty and health related

• What is the relationship between poverty and TB

• Does effective TB control reduce poverty

• Why may DOTS be failing to reach the poor

• How should TB programs improve access for the poor to DOTS

STOP TB and WHO WPRO, 2004

• Is this an opportunity/entry point to push the health equity

agenda via priority public health, disease specific

programs?

• How do we develop a process to support the PPHC KN?• How can we collect information on successful

experiences?

• What diseases• In what time frame

• How do we organize the work• Specific country case study - looking at several priority

programs at the same time? • Specific programs to be looked across in selected countries?

• How to sustain the work after CSDH ends

D. Discussion points

Thank youThank youThank youThank you

Tim EvansTim EvansTim EvansTim Evans

Ritu SadanaRitu SadanaRitu SadanaRitu Sadana

Jeanette Vega Jeanette Vega Jeanette Vega Jeanette Vega