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Background

Across all countries, the major causes of health inequities arise from the social determinants of health (the conditions in which people are born, grow, live, work, and age). Reducing health inequities is not only a moral imperative but will also deliver wider social and economic benefits. In 2008, the WHO Commission on Social Determinants of Health produced an extensive prescription for what is required to “close the gap” across all sectors of society, and at the 2009 World Health Assembly Member States resolved to put those recommendations into practice by adopting Resolution 62.14 “Reducing health inequities through action on the social determinants of health”. This was followed by the 2011 World Conference on Social Determinants of Health, which resulted in the Rio Political Declaration on Social Determinants of Health (1).

Closing health equity gaps requires comprehensive, coordinated actions to address the social determinants of health across sectors. Nonetheless, evidence and experience from inside and outside the Region show that it is entirely possible to reduce health inequities, even in the most challenging areas. Country experiences provide excellent examples of successful actions which can be built on and appropriately transferred to other areas. For example, the experiences of Morocco, the Islamic Republic of Iran and Tunisia are evidence of successful multisectoral collaboration that can largely be used by other countries of the Region.

In this regard, the WHO Urban Health Equity Assessment and Response (Urban HEART) (2) approach is recognized as a platform to unify interventions under one umbrella at the city level. The Urban HEART tool has been successfully implemented in the Islamic Republic of Iran and Morocco to operationalize social determinants of health and address inequities in urban settings.

Nevertheless, there is evidence to show persistent health inequities related to socioeconomic status, gender and urban/rural differences in the Region and countries need help in implementing the recommendations for social determinants of health.

Bringing focus on the matter

Against this background, the WHO Regional Office for the Eastern Mediterranean organized a regional consultation on the social determinants of health on 21–23 April 2015 in Tehran. The meeting was attended by participants from 13 countries of the Region along with experts and staff representing the UNDP and WHO. Participants were charged with finding ways to: motivate key local policy-makers to support work on the social determinants of health; enhance community empowerment in local health and social development; design sustainable mechanisms for intersectoral collaboration and partnership for urban health development; and develop strategies to reduce health inequities.

The specific objectives were to:

share and review actions being taken to operationalize the Rio Declaration at regional and global levels;

identify data gaps related to inequities;

share experiences from within and outside the Region on social determinants of health in conflict and crisis situations;

introduce options and tools to monitor and reduce health inequities, including Urban HEART.

Key issues and challenges

Participants discussed the main components of Regional framework for action on social determinants of health and propose interventions in respect to five domains (advocacy and capacity-building, steps towards identifying data gaps, partnership, governance, and integration of social determinants of health) in five WHO priority areas (communicable diseases, noncommunicable diseases, maternal and child health, health system development and emergencies).

Considering the large number of countries facing conflicts and emergencies in the Eastern Mediterranean Region, a session was entirely devoted to social determinants of health in conflicts and crisis situations. Preparing for crisis – strengthening response interventions through vulnerability reduction, intersectoral actions, city resilience, restructuring of the health system and protecting public health facilities from damage as a result of crisis – should be seriously considered as an integral part of a country’s social determinants of health plan of action.

The main challenges identified were inadequate political commitment by governments and poor recognition of the social determinants of health as a priority. Other problematic areas included: unsustainable leadership; political instability/security; lack of any mechanism to operationalize a national plan for the social determinants of health through defined roles and responsibilities; the absence of disaggregated data on inequities; inadequate institutional alignment and harmonization; lack of communication between different sectors; funding constraints; fragmentation of the health system infrastructure, especially in conflict areas; weak capacity of human resources to address social determinants of health; and low utilization of public health services.

The importance of partnership in tackling the adverse impact of conflicts was highlighted: without sustainable partnership, no development is possible. In this regard, the engagement of the people in priority-setting is the first step in building partnerships.

UN agencies can play a key role in building partnerships at national and regional levels in response to the health inequities. Capacity-building in the local community and their active engagement are crucial elements for implementation of social determinants of health. Countries should be assisted in using a refined Urban HEART as an option to address inequities in urban settings. Closing health inequity gaps requires actions across many sectors, including government, civil society, UN agencies and other development organizations, academic institutions, donors and the private sector.

Countries of the Region need help in implementing the recommendations for social determinants of health, mainly promoting Health in All Policies; incorporating equity, gender and human rights into public health programmes; enhancing linkages between social and environmental determinants of health; monitoring and evaluating social determinants of health; and removing all barriers that hinder access of all to health and other social services. Choosing simple, practical yet informative indicators for monitoring health inequities is essential to proceed with the implementation of the social determinants of health national plan of action.

Monitoring equity indicators is crucial; this comprises five steps: definition of indicators, obtaining data, data analysis, reporting (communicating) the results and implementing changes. Countries also need assistance in using the WHO Global Health Observatory and other tools like Urban HEART to monitor health equity and assist in developing responses in filling equity gaps.

Actions

Member States and WHO agreed to implement a number of components of the proposed regional framework for action on social determinants of health and their related actions, with technical support from WHO. Selected actions are listed in Box 1

References

1. Rio Political Declaration on Social Determinants of Health. World Conference on the Social Determinants of Health. Rio de Janeiro, Brazil, 21 October 2011 (http://www.who.int/sdhconference/declaration/Rio_political_declaration.pdf?ua=1, accessed 22 November 2015).
2. Urban HEART: Urban Health Equity Assessment and Response Tool. Kobe: World Health Organization, The WHO Centre for Health Development; 2010 (http://www.who.int/kobe_centre/publications/urban_heart.pdf?ua=1, accessed 22 November 2015).