Do you consider that WCSDH achieved its objective of defining strategies to combat health inequities through action on SDH? What would you emphasize in this regard?
The WCSDH brought together an impressive range of policymakers, analysts, experts, and advocates –from both within and outside government and international agencies– with extensive experience to share in terms of past and existing strategies to combat health inequities and defining future actions. However, the conference format minimized participation and prevented any real possibility of engaged, accessible, and disseminated exchange and debate over these ideas because the main plenaries were highly structured, often superficial, and with just one exception on the last day (that was itself quickly cut off) precluded questions and comments from the floor. Even the very short session planned for the last day to summarize the discussions of the 10 subplenary roundtables that were at the heart of sharing experiences and defining strategies –including civil society efforts—had to be suspended because excessive time was spent on unnecessary “highlights” of the conference presented by a loquacious and superficial BBC reporter and high-level health officials, some of whom had a troublingly narrow understanding of social determinants of health.
At the level of subplenary roundtables on the second day of the conference, there was discussion of a number of extremely promising strategies to reduce health inequities in the realm of all five conference themes –from citizen participation approaches in Bolivia, Mexico City, Cuba, and Southern Africa, among other settings; to welfare state-building measures in countries as distinct as Brazil and Finland; to public health sector transformations across the world; to the democratic transformation of global governance in such spheres as trade and financial regulation; to the ways in which measuring and monitoring health inequities are central to ensuring accountability, as experienced across the Americas, New Zealand, India, and North Africa, and so on. Nevertheless, because these issues and the summary of the subplenaries were squeezed out of the main plenary, most attendees –including government ministers who met simultaneously and separately from the subplenaries– had no access to the rich array of discussions that took place in these sessions.
Of greatest concern is that the Rio Political Declaration on Social Determinants of Health failed to take into account the many concrete strategies and measures presented at the subplenaries, and the voices and perspectives of public and collective interest civil society organizations and movements, instead compiling a vague, lowest common denominator of actions with no mechanisms for accountability.
In this sense, the conference was a huge missed opportunity for explicit discussion about how the key factors discussed by the WHO’s Commission on Social Determinants of Health as underpinning inequities in health –the unfair distribution of power, resources and wealth– will be tackled by member states and UN agencies.
What steps in short and medium terms member countries should adopt to comply with the commitments made at this conference?;
I believe that the 3 alternative declarations – issued, respectively, by the People’s Health Movement (PHM), the Latin American Social Medicine Association (ALAMES), and the International Federation of Medical Students’ Association (IFMSA), offer effective short-, medium-, and long-term steps member countries can adopt to combat health inequities, and to finance these strategies. These 3 alternative documents could make these recommendations precisely because they did not shy away from naming the political determinants of the social determinants of health.
These alternative measures include implementing:
• universal, free, publicly-financed and delivered, integrated, equity-based health systems (emphasizing comprehensive primary health care) and social security systems from
• community engagement in monitoring, planning, and democratizing health systems
• progressive taxation systems domestically, and global measures to eliminate speculation and tax evasion
• mechanisms for democratic accountability and transparency in global governance and trade, including a transparent system of naming and holding to account the perpetrators (corporate, national, individual) who are responsible for health inequities within and between countries
• an ongoing global monitoring system that shows the role financial capital interests and transnational corporations have (had) in implementing neoliberal economic and social policies that create health inequities, especially given the current global fiscal crisis
• a code of conduct in relation to the management of institutional conflicts of interest in global health decision making
• measures to combat entrenched forms of social and economic deprivation, exclusion, and discrimination on the basis of race, Indigenous status, migrant status, gender, sexuality, disability, etc. both within health systems and in all social realms
• support for alliances of progressive governments and social movements, especially youth movements
What are the main changes in technical cooperation activities that should be undertaken by WHO and other international organizations to support countries in implementing national plans and programs to combat health inequities?
First, technical cooperation does not exist in a vacuum but is shaped and guided by a larger paradigm or analytic framework, one that is necessarily political, and, if I may use the word, ideological. Rather than eschew discussion of the nature of this framework, WHO and other international agencies should consciously, courageously, and openly embrace the idea that in order for health inequities to be addressed effectively, the determination of health must be understood in political and social terms rather than in purely technical terms. This will enable WHO to set an agenda for action that is based upon the findings of the WHO Commission on Social Determinants of Health, in turn defining how WHO can best support the technical needs of national plans and programs aimed at redressing health inequities.
Second, WHO and other UN agencies have become captive to donor interests, with 80% of the WHO budget now earmarked by donors. In order for WHO to play a bona fide role in supporting its members to effectively address health inequities, it must be redemocratized and begin to play a powerful advocacy role at the global level. WHO has an obligation to articulate the role of the concentration of wealth and resources, unbridled corporate power, and unfair trade, in producing health inequities, as demonstrated through a wealth of existing sound knowledge and ongoing research.
What other aspects would you like to point out?
Despite its name, the Rio Political Declaration on Social Determinants of Health was not very political. It should have been far bolder so that alternate declarations did not need to be generated. The 1978 International Conference on Primary Health Care did not need an alternative declaration because its drafting before and during the conference involved multiple member states, civil society organizations, and advocates, and was not dominated by just a few dominating, but unrepresentative players. This made Alma-Ata a far more powerful and truly political (!) document, a declaration to remember and that has been remembered.
ALAMES-Latin American Social Medicine Association [Internet]. [acesso em 15 dez 2011]. Disponível em: http://www.alames.org/
Declaration by Public Interest Civil Society Organisations and Social Movements. Rio de Janeiro, Brasil; 2011.
WCSDH in Rio: Medical students’ perspective on the Rio Declaration [Internet]. France: International Federation of Medical Students’ Associations; 2011 Oct 21 [acesso em 16 dez 2011]; [aproximandamente 1 tela]. Disponível em: http://ifmsa.wordpress.com/2011/10/21/medical-students-perspective-to-the-rio-statement-on-the-social-determinants-of-health/
Entrevista com: Anne-Emanuelle Birn