Report of a Regional Consultation SEA-HE-197 Ms Valerine Kumarasinghe Dr (Ms) Usha Perera Distribution: General Medical Officer – Planning Ms D M Geethani Dissanayake E-mail : [email protected]

Ministry of Healthcare & Nutrition (Local Dr Himan Galappaththi Organizers) Research Assistant (SDH Secretariat) E-mail : [email protected] Dr Sarath Samarage Deputy Director General (Planning) Ms Shantha Perera (Focal Point – SDH Programme in ) E-mail : [email protected] Regional Consultation on

Social Determinants of Health: Addressing Health Inequities

Report of a Regional Consultation , Sri Lanka, 18–20 February 2009

Ministry of Healthcare and Nutrition, Colombo, Sri Lanka in collaboration with WHO Regional Office for South-East Asia, New Delhi

Regional Office for South-East Asia

Page 30 Regional Consultation on Social Determinants of Health: Addressing Health Inequities

Ms Meena Cabral de Mello WHO/SEARO FCH/CAH/ADH Dr Poonam Khetrapal Singh Email: [email protected] Deputy Regional Director, WHO/SEARO E-mail: [email protected] WHO Kobe Center, Japan Dr Jacob Kumaresan, Director Dr Palitha Abeykoon WHO Center for Health Development Ag. Director, Noncommunicable Diseases and World Health Organization Mental Health, WHO/SEARO © World Health Organization 2010 IHD Centre Building 9F E-mail: [email protected] 1-5-1 Wakin0ohama-Kaigandori Chuo-Ku 651 0073, Kobe, Japan Dr A Sattar Yoosuf All rights reserved. Tel: +81 78 230 3100; Fax: +81 (78230) 3178 Director, Sustainable Development and Health E-mail: [email protected] Environments, WHO/SEARO Requests for publications, or for permission to reproduce or translate WHO Email: [email protected] publications – whether for sale or for noncommercial distribution – can be OBSERVERS (Sri Lanka) obtained from Publishing and Sales, World Health Organization, Regional Office Dr B A Jayaweera Dr Davison Munodawafa for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 Ex-WHO Staff Regional Adviser, Health Promotion and 002, India (fax: +91 11 23370197; e-mail: [email protected]). Education, NMH/WHO/SEARO E-mail: [email protected] Dr Tissa Cooray Ex-WHO Staff The designations employed and the presentation of the material in this publication Prof Surinder K. Aggarwal do not imply the expression of any opinion whatsoever on the part of the World TIP-HPE (SDH), NMH/WHO/SEARO Dr M V Gunaratne Health Organization concerning the legal status of any country, territory, city or E-mail: [email protected] Ex-WHO Staff area or of its authorities, or concerning the delimitation of its frontiers or Mr Sunil Kumar Bajaj boundaries. Dotted lines on maps represent approximate border lines for which Dr Pubudu de Senior Administrative Secretary there may not yet be full agreement. Faculty of Medicine HPE/NMH/SEARO University of Colombo E-mail: [email protected] The mention of specific companies or of certain manufacturers’ products does not Dr Padmal de Silva imply that they are endorsed or recommended by the World Health Organization WHO Country Office, Colombo, Sri Lanka in preference to others of a similar nature that are not mentioned. Errors and Faculty of Medicine University of Colombo Dr Agostino Borra omissions excepted, the names of proprietary products are distinguished by initial WHO Representative to Sri Lanka capital letters. Dr Sanath Mahawithanage Nutritionist Dr Kanthi Ariyarathne All reasonable precautions have been taken by the World Health Organization to Fonterra Brand Lanka National Professional Officer (HPE) verify the information contained in this publication. However, the published Dr Shanthi Dlpadadu material is being distributed without warranty of any kind, either expressed or Dr R Kesavan Health Policy Research Associates (Pvt) Ltd. implied. The responsibility for the interpretation and use of the material lies with National Professional Officer (HSD) the reader. In no event shall the World Health Organization be liable for damages Dr Vinya Ariyaratne arising from its use. Executive Director Mr Kolitha Wickramage Sarvodaya Shramadhana Movement TIP, WCO/SRL This publication does not necessarily represent the decisions or policies of the Mrs Myrtle Perera Mr M R Kanaga Rajan World Health Organization. Marga Institute Administrative Officer

Dr Neelamani Hewageegana Mr P.P Singh Printed in India Provincial Director of Health Services Administrative Officer

Page 29 Report of a Regional Consultation Contents Dr Ravi Rannan-Eliya Sir Prof Michael Marmot Director, Institute of Health Policy and Director, International Institute for Society and Research Associate Health Health Policy Research Associates Pvt. Ltd Department of Epidemiology and Public Health 72 Park Street, Colombo, Sri Lanka University College London Page E-mail: [email protected] 1-19 Torrington Place, London WC1E 6BT, Dr Gamini Batuwitage UK Executive summary...... v Additional Secretary Tel: +44 020 7679 1717; Ministry of Nation Building Fax: 44(020) 7813 0242 (Gamidiriya Community Development Project) E-mail: [email protected] 1. Introduction ...... 1 Colombo, Sri Lanka Dr Ruth Bell 1.1 Background of work in the Regional Office for South-East Asia...... 1 University College London Dr Viroj Tangcharoensathien 1.2 General objective...... 2 Director 1-19 Torrington Place International Health Policy Program (IHPP) London WC1E 6BT, UK 1.3 Specific objectives...... 2 Ministry of Public Health Tel: 00-44-0207 679 1684; Tiwanond Road, Amphur Muang Fax: 0207 813 0242 1.4 Expected outcomes...... 2 Nonthaburi 11000, Thailand E-mail: [email protected] Tel: 66-081-8480297 E-mail: [email protected] Dr K. Karalliedde 2. Inaugural session ...... 3 Great Ormond Street Hospital Dr Suphot Dendoung London, U.K. Associate Professor 3. Business sessions ...... 3 Medical and Health Social Sciences Programme WHO Secretariat Faculty of Social Sciences and Humanities 3.1 Regional and global overview of SDH experiences ...... 3 WHO/HQ Mahidol University at Salaya Nakornpathom 73170, Thailand Dr K.C. Tang 3.2 Exchange of country experiences ...... 6 Tel (office): (66-2) 441-0220-2 ext. 1104, 1235, HPR/NMH 3.3 Actions to improve daily living conditions...... 6 Fax (office): (66-2) 441-9738 E-mail: [email protected] E-mail: [email protected]; 3.4 Sri Lanka’s experiences on social determinants of health ...... 7 [email protected] Dr Eugenio Raul Villar Montesinos Coordinator 3.5 Tackling the inequitable distribution of power, money and resources...8 Dr Kan Tun Department of Ethics, Equity, Trade and Human 3.6 Measure and understand the problem and assess the impact of action .9 Former WHO Representative to Sri Lanka Rights (ETH) 151, Jalan Datuk Sulaiman Information Evidence and Research (IER) 3.7 Group work and report back...... 10 Taman Tun Dr Ismail E-mail: [email protected] 60000 Kuala Lumpur Tel: +60122108485 Ms Nicole Valentine 4. Recommendations...... 10 E-mail: [email protected] Acting Coordinator, Equity and Social Determinants Implementation Country Work Focal Point, Commission on Social Determinants 5. Conclusion ...... 11 of Health Secretariat Department of Ethics, Equity, Trade and Human Rights Information, Evidence and Research WHO/HQ E-mail: [email protected]

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Annexes Dr Walaiporn Patcharanarumol Ms Bijal S. Brahmbhatt Thailand 1. Message by Hon. Prime Minister, Sri Lanka ...... 12 Co-ordinator, MHT-SEWA 404, Mahila Housing SEWA Trust Prof Wanicha Chuenkongkaew Akash Ganga Complex, Navrang Pura 2. Message from Regional Director, WHO South-East Asia Region .... 13 Faculty of Medicine Ahmedabad – 380 006 Gujarat, India Mahidol University Tel: 0179-25506444, 25506477; 3. Message by Hon. Minister of Healthcare and Nutrition, Sri Lanka .. 16 2, Pranov Road, Bangkoknoi Mobile: 9198 2502 9281 Bangkok, Thailand 10700 E-mail: [email protected] 4. The Colombo Call for Action ...... 18 Tel: 662-4197680, Fax: 662-4197679 E-mail: [email protected] 5. Agenda ...... 21 Ms Nandita Bhan Research Fellow-SDH Participants & Resource Persons 6. Programme ...... 22 Public Health Foundation of India (PHFI) Dr Shahaduz Zaman PHD House – 2nd Floor 7. List of Participants ...... 25 Associate Professor 4/2, Sirifort Institutional Area James P. Grant School of Public Health August Kranti Marg, New Delhi 110016, India BRAC University Tel. 91 – 11- 46046000/Ext. 229; 46046034 66, Mohakhali, Dhaka 1212, Bangladesh E-mail: [email protected] Tel: 88-02-988 1265/Ext. 4162; Mobile: 88-01819215694 Professor Amiya Kumar Bagchi E-mail: [email protected]; Professor [email protected] Institute of Development Studies Kolkata, Calcutta University Alipore Campus Dr Charles Surjadi 1 Reformatory Street, Fifth Floor, Center for Health Research Kolkata 700027, India Atma Jaya Catholic University Phone: +91-33-244889335; Jalan Pluit Raya No 2 Kompleks RS Atmajaya 244882225/1364/9331 Jakarta 14440, Indonesia (R) +91-33-24732796 Tel: 62-21-660 6127/Ext. 234; Fax: +91-33-24481364 Fax: 62-21-688 2512 E-mail: [email protected]; E-mail: [email protected]; [email protected] [email protected] Ms Mirai Chatterjee Mr Javid A. Chowdhury Commissioner & Coordinator SEWA D-202, Anand Lok Apartments Self-Employed Women’s Association Mayur Vihar, Phase-I, Delhi 110091 Ahmedabad – 380 006, Gujarat, India Tel: 91 11 22793483; Mobile: 9212113184 Email: [email protected] Email: [email protected] Dr S.D. Gupta Prof A.M. Khan Director Head, Department of Social Sciences Indian Institute of Health Management Research National Institute of Health and Family Welfare (IIHMR) Munirka, New Delhi-110 067, India 1, Prabhu Dayal Marg, Sanganer Airport Tel: 91-11-26100538; Mobile: 9811833786 Jaipur 302001, Rajasthan, India E-mail: [email protected] Tel: 91-141-2791431-34; Fax: 91-141-2792138 Email: [email protected]

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MALDIVES Prof Saroj Jayasinghe Dr Ibrahim Yasir Ahmed Professor Director General of Health Services International Medical University Ministry of Health and Family Clinical School Seremban Malé Jalan Rasah, 70300 Seremban Tel: +960-3313373; Fax: +960-3324462 Malayasia Executive summary E-mail: [email protected] Tel: 60(6) 7677798; Fax: 60(6) 7677709 E-mail: [email protected] The Consultation acknowledged the existence of inequities and inequalities Ms Aishath Samiya in health among and within countries of the World Health Organization’s Deputy Director Dr STC Mahawithanage Policy, Planning Division Project Director South-East Asia (WHO SEA) Region. There was concurrence that climate Ministry of Health and Family 23/90, Wasanawata change, urbanization and globalization, among others, could further Malé Mattegoda, Sri Lanka exacerbate the inequities among and within countries. Evidence was Tel: 00-960-7783533 Tel: -773-401584 presented showing that health inequities could be reduced if a social justice E-mail: [email protected] E-mail: [email protected] THAILAND approach to health was adopted. Such an approach calls for the NEPAL involvement of other sectors because the causes of ill health and premature Mrs Kannikar Bunteongjit Dr Babu Ram Marasini deaths exist outside the health domain. It was also made clear that Deputy Secretary-General, National Health Senior Health Administrator improving living conditions; tackling unequal distribution of power, money Commission Office Ministry of Health and Population A2, 88/34 Tiwanon Road and resources; and improving routine monitoring of health inequity were Ram Shah Path Tiwanon Road Kathmandu central to closing the health equity gap. Nonthaburi 11000, Thailand Tel: 977-1-4262896; Fax: 977-1-4262484 E-mail: [email protected] Several WHO SEA Region countries have taken a wide range of Dr Thaksaphon Thammarangsi actions to close this equity gap by addressing the social determinants of SRI LANKA Senior Research Scholar, International Health Policy Program (IHPP) health. Some such actions include the contributory social security system Mr Abeygunwardane Ministry of Public Health, Tiwanon Road, Muang for self-employed women in India, subsidized micro credit to the poorest in Director General District Bangladesh, abolishment of bonded (child) labour in Nepal, provision of National Planning Nonthaburi 11000, Thailand Ministry of Finance, Colombo Tel: (662) 590 2366; Fax: (662) 590-2385 universal healthcare in Thailand, adoption of the Gross National Happiness E-mail: [email protected] Index as a measure of human development, introduction of health Dr (Ms) Amala De Silva insurance in the Maldives, health insurance for the poor and near-poor in University of Colombo Participants from MoPH, Thailand Indonesia, and a progressive pattern of health financing in Sri Lanka. The Sri Lanka Dr Pongthep Sutheravut meeting strongly recommended documenting and sharing of these Thailand Dr Godfrey Gunatillake experiences as well as scaling up these innovations within countries and the Chairman, Marga Institute Ms Nattaya Thaennin Region. 93/10 Dutugemunu Street National Health Commission Office (NHCO) Kirullapone, Colombo Fl. 2, 88/37 Tiwananon Road Tel: 00-94-1-828544 In conclusion, the Consultation agreed to tackle health inequities Muang District, Nontaburi E-mail: [email protected] within and across countries through political commitment to “closing the Thailand 11000 Tel: 66-2590 2477; Fax: 66-2590 2311 gap in a generation”. The “Colombo Call for Action” which urges countries Professor Siri Hettige E-mail: [email protected] to mainstream health equity in all policies, empower individuals and SPARC, University of Colombo Sri Lanka communities and advocate good governance and corporate social Mr Jaruek Chairak E-mail: [email protected] responsibilities, was unanimously endorsed for adoption. Thailand

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Annex -7 List of Participants

Hon. Health Ministers, SEAR countries Prof Mala Rao Indian Institute of Public Health Hon Dr A F M Ruhal Haque Vengal Rao Nagar Minister of Health, Bangladesh Hydereabad (Andhra Pradesh) E-mail: [email protected] Tel: +91 4- 237173/237174/Ext. 21; Mobile:+919703410202 Hon Lyonopo Zangley Dupka E-mail: [email protected] Minister of Health, Bhutan E-mail: [email protected] INDONESIA Hon Dr Aminath Jameel Dr Budiharadja Singgh Minister of Health and Family, Maldives Director, Bureau of Public Health E-mail: [email protected] Jatiwarna IND&H, Jl. Bungaa Matahavi IX Block J-21, Bekasi 17415 Hon Nimal Siripala de Silva Jakarta Minister of Healthcare and Nutrition, Sri Lanka Tel: +62-21-84998334; Fax: 62-21-84998334 E-mail: [email protected] E-mail: [email protected]

Country Participants Mr Naydial Roesdal Senior Adviser to Minister of Health BANGLADESH Ministry of Health Mr Md. Abdul Mannan Jln. H.R. RASUNA Said Kav 4-9 Block X-5 Joint Chief (Planning) Jakarta 12950 Ministry of Health and Family Welfare, Dhaka Tel: 62-21-5203881 E-mail: [email protected] BHUTAN Mr Abdurachman Mr Namgyal Dorjee Director Private Secretary Centre for Planning Ministry of Health Ministry of Health Royal Government of Bhutan Jakarta Thimphu Tel: 62-21-6502996 Tel: +975 2323973 E-mail: [email protected] E-mail: [email protected] Dr Iswandi Mourbas INDIA Chief of Division Short-term Health Mrs Ganga Murthy Development and Policy Analysis Economic Adviser Ministry of Health Ministry of Health and Family Welfare Jakarta Nirman Bhawan, New Delhi Jln. H.R. RASUNA Said Kav 4-9 Block X-5 Tel: 91-11-23061028, Fax: 91-11-23061730 Jakarta 12950 Mobile: 9810752495 Tel: 62-21-5214903 E-mail: [email protected] E-mail: [email protected]

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1. Introduction

Session 5: Group Work 1.1 Background of work in the Regional Office for South-East Strategic actions to address SDH related inequities in health. Asia ¾ Health sector response – Group 1 ¾ Multi-sectoral partnership – Group 2 In 2004, during the World Health Assembly, The WHO Director-General 10:30 – 12:00 ¾ Role and responsibilities of government – Group 3 announced the need to establish a process to address the social causes of ¾ Call to Action – Group 4 illness, health inequities and premature deaths. His call for the 12:00 – 13:00 ¾ Group Work Report Back and Consensus Building Session establishment of a Commission on Social Determinants of Health (CSDH) was implemented in March 2005. The specific goals of the Commission Session 6: Presentations and Discussions were to: Measure and understand the problem and assess the impact of action (1) Support health policy change in countries by assembling and ¾ Government of India experience to measure and understand health equity by Ms Ganga Murthy, promoting effective evidence-based models and practices that address 14:00 – 15:30 the social determinants of health; ¾ Social, cultural and behavioral research by Prof A.M. Khan ¾ Understanding the problem: SDH and evidence by Dr. Ruth Bell (2) Support countries in placing health equity as a shared goal to which Discussion many government departments and sectors of society contribute; (3) Help build a sustainable global movement for action on health equity Session 7: Summary Recommendations and Closing Chairperson: Hon Nimal Siripala De Silva, Minister of Healthcare and Nutrition, Sri Lanka and social determinants through the linking of governments, international organizations, research institutions, civil society and ¾ Presentation of Summary Recommendations 16:00 – 16:30 communities. ¾ Presentation and Adoption of The Colombo Call to Action. Closing The CSDH Commissioners held a meeting in the WHO Regional Office for South-East Asia (SEARO), New Delhi, on 15–16 September 2005 16:30 – 17:00 Remarks by: Sir Michael Marmot; WR Sri Lanka; WHO SEARO and Hon Nimal to introduce the work of the Commission and to request the Regional Siripala De Silva, Minister of Healthcare and Nutrition, Sri Lanka. Office for its technical support for work at the country level. The Regional Adviser, Health Promotion and Education, was appointed as the focal point and the Department of Non-communicable Diseases and Mental Health (NMH) as the Secretariat. Since then, the SEA Regional Office for South- East Asia and CSDH have worked closely on advocating activities at the country, regional and global levels for addressing the SDH issue.

The Regional Office is collaborating with the WHO Kobe Centre (WKC), Japan, to address social determinants among urban populations. This work was initially conducted under the Knowledge Network on Urban Settings (KNUS) and WKC, Japan. Sri Lanka has established a working group on SDH and the SEA Regional Office has provided technical support to this initiative. In February 2007, the SEA Regional Office and WHO Headquarters (WHO-HQ) conducted a joint mission with Sri Lanka to support its work on SDH. This mission developed and implemented several

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activities based on discussions and agreements with an intersectoral group 12:00 – 12:30 Discussion comprising members from government, civil society and donors. The Regional Office held a Regional Consultation on Social Determinants of Session 3: Panel Discussion Health in Colombo, Sri Lanka, from 2–4 October 2007. The Regional Chairperson: Hon Dr AFM Ruhal Haque, Minister of Health Bangladesh; Co-Chair: Dr Abrahim Office also commissioned six-country case studies to document the Yasir Ahmed, Director General of Health Services, Maldives evidence on health and healthcare inequities in the selected Member “Actions to improve daily living conditions.” States. Country and regional analyses were completed by the Institute of Healthy Urbanization Health Policy (IHP), Sri Lanka, and the International Institute of Health 13:30 – 14:00 ¾ Dr Jacob Kumaresan Policy (IIHP), Thailand. The current Consultation was planned and finalized ¾ Ms Bijal Bhatt during a side-meeting held during the conference on “Closing the Gap in a 14:00 – 14:15 Discussion Generation” at London in November 2007. Public Health Policies and Programmes 14:15 – 14:45 ¾ Dr Godfrey Gunatillake, 1.2 General objective ¾ Dr Viroj Tangcharoensathien 14:45 – 15:00 Discussion The general objective of this initiative is to place health equity as a shared Session 3: Sri Lanka Experiences on Social Determinants of Health goal of governments and sectors of society and address or tackle their social determinants. ¾ Dr Gamini Batuwitage ¾ Prof. Saroj Jayasinghe 15:30 – 16:30 ¾ Dr Vinya Ariyarathne 1.3 Specific objectives ¾ Prof. Siri Hettige (1) To exchange global, regional and national experiences related to ¾ Dr Sarath Samarage tackling health inequities and their social determinants; 16:30 – 17:00 Discussion

(2) To draw relevant implications for SEA Region countries arising from Day 2 – Friday, 20 February, 2009 the overarching recommendations of the WHO CSDH Report; and 08:30 – 08:45 Reflections of Day One by Prof Sir Michael Marmot (3) To reach consensus on SEA Regional approaches to “close the equity gap” through action on SDH. Session 4: Panel Discussion Chairperson: Hon Dr. Aminath Jameel, Minister of Health, Maldives; Co-Chair: Dr. Viroj Tangcharoensathien, Dir, Int’l Health Policy, Thailand. 1.4 Expected outcomes Tackle the inequitable distribution of power, money and resources (1) Propose recommendations to Member States and WHO for Climate change, globalization and economic crisis: ¾ Economic crisis and its impact – Prof. Amiya Bagchi strengthening the work to tackle inequities and their social 08:45– 09:45 determinants; and ¾ Globalization and health by Dr Suphot Dendoung ¾ Climate change and health- Ms Nandita Bhan

(2) Commitment from representatives of countries and other sectors of 09:45 – 10:00 Discussion society and WHO to the recommendations emerging from the (Preview of BHUP video ) Consultation. 10:00 – 10:30

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Annex-6 2. Inaugural session Programme The consultation was formally inaugurated by H.E. Hon. Rathnasiri Wickramanayake, the Prime Minister of Sri Lanka. The delegates were Venue: Cinnamon Grand Hotel, Colombo, Sri Lanka welcomed by the Secretary of Health, Sri Lanka. In his keynote address, the Hon. Prime Minister underlined the importance of this meeting in view of the insecure worldwide social, economic and political environment. The 18 February 2009 inaugural session was also addressed by the Hon. Nimal Siripala de Silva, Inauguration by Government of Sri Lanka Minister of Healthcare and Nutrition, Sri Lanka, who reiterated the strategic significance of the work of the Commission since the findings of CSDH

were an important agenda for discussion at the recent Executive Board Day 1 – Thursday, 19 February 2009 meeting of WHO. He also stressed that Sri Lanka has been a pioneer in 08:00 – 09:00 Registration addressing SDH in achieving good health standards and will further strengthen efforts to sustain health outcomes and face new healthcare Session 1 challenges. Dr Poonam Singh, Deputy Regional Director, WHO SEA Overview of SDH Experiences Regional Office, read the inaugural message of Dr. Samlee Pilanbangchang, Chairperson: Hon Lyonopo Zangley Dupka, Minister of Health, Bhutan; Co-Chair: Dr. WHO Regional Director for South-East Asia. The message emphasized the Budiharaoja, Director General of Community Health, Indonesia need to create political commitment and examine the stewardship role of ¾ An overview of SDH : SEARO Experience - Dr Davison Munodawafa governments in a globalized world to address SDH, including health in all ¾ An overview of SDH : WHO HQ Experience – Dr Eugenio Raul Villar policies, health financing and intersectoral action. In his address, Sir Montesinos 09:00 - 10:30 Professor Michael Marmot, Chairman, CSDH, congratulated the Sri Lankan ¾ An Overview of the Commission on Social Determinants of Health Government for holding the consultation in Colombo and thanked the Report Recommendations by Prof Sir Michael Marmot and Mirai Chatterjee countries of the WHO South-East Asia Region for taking the lead in the discussions and recommendations of the Commission’s Report and hoped ¾ Introduction of participants: Dr Kanthi Ariyarathne, WHO Country that consensus would be reached on taking forward the implementation of Office 10:30 – 11:00 selected recommendations. ¾ Group Photograph

Session 2 Exchange of Country Experiences 3. Business sessions Global, regional and national experiences to tackle health inequalities and 3.1 Regional and global overview of SDH experiences social determinants of health: ¾ Mr Javid A. Chowdhury - Health security and equity: Experiences The Chair of the session, the Hon. Minister of Health, Bhutan, referred to from India. 11:00 – 12:00 the Gross National Happiness Index in Bhutan vis-à-vis its link to addressing ¾ Mrs. Kannikar Bautoengjit SDH. The Minister also made reference to the current global financial and ¾ Dr Ravi Rannan-Eliya - Equity in Health economic crisis in global capitalism and bemoaned that greed cannot be ¾ Prof. K. Karalliedde – Inter sectoral Program for Children with needs: the principle of human development. He concluded by stating that the London Experience need to explore alternate governance structures and conceptual paradigm

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shifts such as growth with equity and justice that are espoused in the SDH Annex-5 approach. Agenda The experience of the SEA Region was presented by Dr Davison Munodawafa, Regional Advisor, Health Promotion and Focal Point for Social Determinants of Health. The global perspective was delivered by Dr Inauguration (Government of Sri Lanka) Eugenio Raul Villar Montesinos from WHO-HQ. Session 1: Technical Session: Overview of the CSDH The Regional perspective illustrates that countries of the SEA Region recommendations. are engaged in SDH actions, namely advocacy, awareness and evidence ¾ Prof Sir Michael Marmot and Mirai Chatterjee generation. India and Sri Lanka have participated in the work of the Commission on Social Determinants of Health as country partners for Session 2: Exchange of global, regional and national experiences. health urbanization and intersectoral action. Six SEA Region countries (Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand) conducted Session 3: Round Table Discussion: Actions to improve daily living health equity analysis using Demographic Health Survey (DHS. A report has conditions: been produced reflecting the regional profile regarding health equity gaps. ¾ Healthy Urbanization The empowerment of self-employed women was also documented using ¾ Public Health Policies and Programmes the SEWA experience. In order to move forward in addressing SDH among SEA Region countries, there is a need to act on the following aspects: Session 4: Presentation and Discussions: Tackle the inequitable distribution of power, money and resources; ¾ Strengthening health systems in order to make them responsive to addressing SDH; Session 5: Presentation and Discussions: Measure and understand the ¾ Gather more evidence and disseminate results for policy and problem and assess the impact of action. program implementation; and Session 6: Summary, Conclusion and Recommendations ¾ Address SDH, MDGs and health system strengthening (HSS) in an inclusive manner. Session 7: Closing

The global perspective traced SDH developments from the establishment of the Commission by the late Director General Dr J.W. Lee in March 2005 to the production, launch and dissemination of the Report of CSDH in August 2008. The CSDH Report has been discussed in WHO Regional Committees and key global meetings. More recently in January 2009, it was discussed at the 124th Executive Board Meeting of WHO and a resolution was approved for the 62nd World Health Assembly scheduled for May 2009 in Geneva. The Resolution expressed appreciation for the work of CSDH and placed the Report within a historical continuity in the struggle for health equity (i.e., the WHO Constitution, primary health care (PHC)/health for all (HFA), Ottawa Charter, MDGs], renewal of PHC, health promotion and environmental action). It also calls on the international

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(8) Establish national institutional mechanisms to coordinate and community to take action along with WHO and its Member States on SDH manage inter-sectoral action for health in order to mainstream and calls on Member States for comprehensive, inclusive and intersectoral health equity in all policies, and, where appropriate, by using action to reduce inequities through the SDH approach. It also called on health and health equity impact assessment tools. WHO Director-General to align PHC and SDH and to convene a global (9) Improve the technical capacity of Member States to plan, meeting to share the progress made on the implementation. implement, measure and evaluate health inequities and social Professor Sir Michael Marmot presented the CSDH recommendations determinants of health. and noted that Brazil, Chile, the UK and Canada are translating the findings (10) Develop, strengthen and reinforce the information systems in of the Commission into programmes. He acknowledged the efforts of WHO various sectors, to routinely generate data and produce evidence SEA Region countries for the practical uptake of SDH advocacy and action. on health inequities (disaggregated by age, gender, ethnicity, However, major challenges remain in closing the gap through addressing social groups, employment status, socioeconomic status, urban SDH and these include: and rural and where appropriate, country specific stratifications) and their determinants, in order to keep the focus on and ¾ Empowerment of women and other marginalized population monitor progress in implementation of policies and programmes. groups; (11) Report and share with different constituencies the evidence on ¾ Action on structural drivers of the conditions in which people health inequities in order to advocate and sustain inter-sectoral are born, live, work and age; actions on a regular basis. ¾ Generating basic information and evidence as a prerequisite to (12) Develop and promote a network of individuals and institutions in, identify or detect inequities; but not confined to, the Region, in order to facilitate collaborative ¾ Strengthening training and research on SDH and establishing a research, sharing of information, experiences and best practices. global health equity monitoring and surveillance system with (13) Take cognizance of widening health inequities as a result of stewardship and technical support from WHO; globalization and urbanization, and advocate for good ¾ Placing fairness in health at the heart of the development agenda governance and corporate social responsibilities at local and and re-commitment to a multilateral system in which all global levels. countries engage with an equitable voice for good governance; (14) Draw the attention of all WHO Member States and stakeholders ¾ Reviewing major governmental and other programmes through to the Colombo Call for Action during the Sixty-second World the equity lens. Action has to involve several groups and sectors Health Assembly and at the Sixty-second session of the Regional working together; Committee for South-East Asia, and at other relevant global and ¾ Focusing on areas and districts which are in special need and set regional fora. up Adopted by the Ministers and delegates attending the “Regional • integrated, intersectoral programmes with SDH focus; and Consultation on Social Determinants of Health: Addressing Health Inequities,” ¾ Ensuring social security for the poor and those in the informal chaired by H.E. Mr Nimal Siripala de Silva, Minister of Healthcare and sectors with Nutrition, Sri Lanka; H.E. Dr A F M Ruhal Haque, Minister of Health, Bangladesh; H.E. Lyonopo Zangley Dupka, Minister of Health, Bhutan; and • legal arrangements (as in India, Nepal and Thailand) and by H.E Dr Aminath Jameel, Minister of Health and Family, Maldives. implementing insurance, maternity benefits and pensions through civil society groups. Colombo, Sri Lanka, 20 February 2009

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It must be ensured that this is carried forward and establish new insurance for the poor and near-poor in Indonesia, progressive pattern of benchmarks of success in order to validate the work of the Commission. health financing in Sri Lanka and other initiatives in Member States in the South-East Asia Reigon.

3.2 Exchange of country experiences We call upon the Member States, civil society, academia, development partners, the private sector, WHO and other relevant Experiences regarding the extent and status of health equities among SEA stakeholders to: Region countries were shared. The causes of inequality and inequity in (1) Tackle the health inequities within and across Member States in health outcomes in these countries are largely due to social and the Region through political commitment on “closing the gap in environmental factors associated with variations in education of the mother a generation” as a national agenda in Member States. and access to healthcare services. Moreover, the role of good medical care (2) Advocate actions on social determinants of health and apply the in improving health outcomes was acknowledged in the presentations using overarching recommendations of the Commission on Social the example of Sri Lanka. In Thailand, the National Health Commission Determinants of Health to the country context in order to (NHC) and National Health Assembly (NHA) coordinate and link political, mainstream “health equity in all policies”. social and wisdom power to achieve health. This is referred to as the (3) Use the current global concerns such as food and energy “Triangle that moves the Mountain”. security, water availability, economic crises and climate change, as an opportunity for action on the social determinants of health 3.3 Actions to improve daily living conditions and prioritize investment in effective inter-sectoral actions to reduce the burden of diseases among the vulnerable population, The impact of public health policies and programmes on urbanization and in particular, prevention of low birth weight and child marriage, health were discussed in the context of the actions required to improve develop and expand early child development programmes, daily living conditions using examples from the WHO Kobe Centre in improve work conditions, strengthen social security systems and Japan, SEWA in Gujarat, India, and Thailand. Rapid and unplanned empower vulnerable groups. urbanization produces inequities and inequalities in health outcomes, (4) Develop national strategies and plans of action, to assess the particularly for vulnerable groups and settings. In order to measure and scope and magnitude, causes and profile of health inequities, understand the problem and assess the impact of action, thw WHO Kobe establish or strengthen where appropriate, inter-sectoral Centre, Japan, has developed an Urban Health Assessment Response Tool mechanisms and build and sustain capacity to implement the (HEART) to monitor the progress in urban health indicators across settings. national plans of action and monitor progress. Poor health conditions and other deprivations in urban slums resulting (5) Develop policies and a legal framework on the citizen’s largely from poor environmental infrastructure, degraded housing, lack of entitlements to universal education, healthcare and relevant power and access to any healthcare system can be improved by a social protection throughout the life course. multisectoral partnership and community participation approach. A total (6) Contribute to the empowerment of individuals, in particular human development approach is preferable for tackling health inequalities women and vulnerable groups, through employment generation, and other deprivations. Within this universal framework, priority can be access to finances and skill improvement, and improvements in given to urban and social sectors with deprived entitlements like decent their societal conditions. living conditions, including access to housing, water and sanitation. (7) Scale-up country-specific innovations that successfully address The predominance of non-communicable diseases (NCDs) requires health inequities through a social determinants approach, and that access to healthcare be the strategic approach to tackle health share lessons across Member States in the Region.

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inequities. A significant part of the health inequalities in NCDs arises from escalating costs of medical care and the prohibitive prices of life-saving or Annex-4 life-prolonging drugs and procedures. Thailand has demonstrated that scaling up social protection across life course and universal coverage and The Colombo Call for Action progressive financing of healthcare is central to achieving better health. It is also critical that there be better understanding of contributions by the non- We, the Ministers and delegates attending the regional consultation on health sector to promote healthy places and healthy people by providing Social Determinants of Health: Addressing Health Inequities through Action full and decent work opportunities. on Social Determinants of Health, organized by the Ministry of Healthcare and Nutrition, Sri Lanka, in collaboration with the World Health Organization, in Colombo, Sri Lanka, on 18-20 February 2009 reached a 3.4 Sri Lanka’s experiences on social determinants of health consensus to close the health equity gap through concerted action on the social determinants of health. The Sri Lankan experiences were drawn from: (i) the Sarvodaya and Shramadan Movement; (ii) the Gemidiriya Community Development and We recognize the existence of inequities in health among and within Livelihood Improvement Project; (iii) a geo-spatial approach analysis; (iv) Member States in the South-East Asia Region. We are concerned that, in experience and strategies for addressing SDH in Sri Lanka; and (v) the addition to social determinants of health, climate change, globalization and plantation sector in Sri Lanka. urbanization could further worsen these inequities by differentially impacting on population groups and lead to preventable premature deaths Sri Lanka has been involved in SDH-related activities with the and disability from communicable diseases, non-communicable diseases Commission and the SEA Regional Office. The political leadership and civil and injuries. society groups have taken a serious interest in the adoption of the SDH approach to reduce further health inequities, particularly by strengthening We appreciate the efforts of the WHO Commission on Social the health system, data collection, research and analysis. The country is Determinants of Health (CSDH), governments, civil society groups, the looking forward to establish institutions like a National Health Council or a World Health Organization and development partners to advocate, high-level commission (or task force or committee) to act on SDH. promote and support the efforts towards closing the health equity gaps using a wide range of inter-sectoral actions. Sri Lanka has a long and committed experience in community and state-driven initiatives in the social and health sectors. Despite the low per We recognize the growing evidence suggesting that social capita income, Sri Lanka has impressive basic health indicators such as determinants of health should be addressed by multiple stakeholders in the infant mortality rate (IMR), maternal mortality rate (MMR), life expectancy health and other sectors, and include measures to improve living and total fertility rate (TFR). This has been largely possible due to the conditions, tackling unequal distribution of power, money and resources, Government’s concern and approach to achieve overall human and routine monitoring of health inequity. development with equity. Civil society groups have remained active partners of the Government and also taken independent initiatives for the We acknowledge the steps taken by individual Member States such as social wellbeing of the community and comprehensive development of the contributory social security system for self-employed women in India, rural and urban settings. With the growing disease burden of NCDs, it is subsidized micro-credit to the poorest in Bangladesh, abolishment of bonded now gearing its resources and institutional mechanism to strengthen its child labour in Nepal, provision of universal health care in Thailand, health system. This is a new challenge for the health sector. adoption of a Gross National Happiness Index as a measure of human development in Bhutan, introduction of health insurance in Maldives, health

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Most initiatives remain largely in the domain of comprehensive addressing crucial health inequities in our country and our region. I wish community development activities such as the Sarvodaya and Sharmadan the conference all success and encourage all the visitors who have come to movement and Gemidiriya Community Development and Livelihood our isle to enjoy a taste of Sri Lankan hospitality. Improvement Project which focus on empowerment of communities through access to micro credit, generation of livelihood and development of basic amenities and services. An integrated “spatial”, “sectoral” and “targeted group” approach has been preferred to vertical programmes for vulnerable populations, such as the plantation sector in Sri Lanka.

3.5 Tackling the inequitable distribution of power, money and resources

The panellists discussed the current global economic crisis, climate change and globalization, focusing on their impact on health outcomes. The modernization theory based on liberalization of economies or trade was considered a major contributor to inequity. Exploitation of the periphery by the core capital system was viewed as the major cause of market failure and thus affecting social sectors like health. In addition, the rules of globalization and unfavourable governance structures at the global level are biased in favour of richer countries and have adverse impacts on poorer countries and vulnerable population groups. Considering the deficiencies in the present economic thinking linked with the globalization process, there is a need to develop new concepts (e.g. the Buddhist concept) that provide a new vision for society with integration of social justice and development and can also simultaneously accommodate health and wealth.

Likewise, the prevailing and potential impact of climate change on health is well recognized. The impact includes heat and cold waves affecting, especially, the elderly; the rising number of deaths among the homeless and disadvantaged; crop failures due to climatic vagaries leading to loss of income for farmers and rise in suicides. In addition, as the sea level rises, coastal cities become vulnerable; and there is resurgence and emergence of certain infectious diseases, such as malaria, in high altitude areas. All these adverse effects of climate change affect poorer and marginalized groups much more than others and this would lead to a worsening of health inequities. It is essential to have the political will and resources to manage climate change with a common global mandate. Also, there is strong need to undertake

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health impact studies to produce strong evidence for possible policy and strategic interventions by the SEA Region countries. Annex-3 Message by Hon. Minister of Healthcare 3.6 Measure and understand the problem and assess the impact and Nutrition, Sri Lanka of action Technical presentations on evidence gathering, dissemination and utilization, policy formulation and behavioural research on SDH were It is my privilege to give this message at this occasion of the Regional presented by three experts. It is well recognized that health gaps exist Consultation on Social Determinants of Health. Up until now Sri Lanka has between men and women, between geographic locations including rural achieved extraordinary good health outcomes compared to the level of and urban settings, and within and between vulnerable and élite groups. spending on health. This is because over the years the political leadership There are differential exposures, vulnerabilities and consequences on and our policymakers of the time gave the highest importance to equity aspects such as housing conditions, education, health-impacting behaviour and social justice in all their social sector policies. In fact many analysts of (smoking, drinking, diet), migration, employment conditions, social isolation the Sri Lankan scene have often described Sri Lanka as an ultimate welfare and childhood immunization. To halt or reverse the conditions in which state. Consequently we have a population that is highly literate, particularly people are born, live and work, action should include structural drivers of among the females. We have had universal healthcare totally free to the these conditions at the global, national and local levels. users, and a series of poverty alleviation programs aimed at improving the livelihoods of the poorer segments of our society. On the side of the health Conflict exists between the scientific and conventional concepts of care, we had adopted primary health care principles during the past four health. Unless this conflict is managed, there may not be any significant decades, starting even before the historic Alma Ata Conference, combined progress among deprived communities despite the availability of health with a well trained and competent health workforce. Yet at the same time infrastructure. Most health-related research with a social science the demographic pattern and the epidemiology profile are changing rapidly perspective lacks a strong conceptual and methodological design, including as shown by the fast ageing population on the one hand and a double findings grounded in either social or behavioral theory. The volume of burden of diseases on the other. These transitions are exerting very serious qualitative research conducted on public health issues is insignificant and pressures on the health system and level and the quality of services that we utilization of results in policy and programmatic decisions is also limited. can manage to provide on a sustainable basis. The chronic diseases among the ageing population and the high technology that is now increasingly The presenters identified the following key elements for measuring being introduced and being demanded by the people have added serious and understanding the SDH problem and assessing the impact of action: constraints to the public sector health budget. His Excellency Mahinda Rajapakse, who in his Mahinda Chintanaya, which expresses his philosophy ¾ Encouraging qualitative and quantitative researchers to and vision, has made equity and social justice the cornerstones of collaborate and exchange information in order to have in-depth development. The three main recommendations of the Commission for understanding of the target population; improving daily living conditions, tackling inequitable distribution of power, ¾ Building the capacity of stakeholders to collect data and analyse money and resources and understanding and assessing the impact of our equity issues; actions-are very similar to the major strategies outlined in the Mahinda ¾ Chintanaya. I am sure that all recommendations that will come out of the Documenting and sharing the experiences of individual deliberations at this very important conference will be highly relevant to countries and institutions on SDH actions in order to influence programmes of intervention; and

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¾ Establishing a national health equity surveillance system with ¾ Examine the stewardship role of the government in a globalizing routine collection of data on social determinants of health and world to address social determinants of health including health health inequity. in all policies, health financing and intersectoral action.

I would like to take this opportunity to reaffirm that the WHO South- 3.7 Group work and report back East Asia Region stands ready to support Member States, local research and academic institutions, and civil society groups to close the health equity gap Four working groups discussed and shared their views on themes related to: through addressing social determinants of health. We are encouraged by (i) Health sector response to reduce the health equity gap; (ii) multisectoral the work of the Commission on Social Determinants of Health and wish to partnership to promote action on the SDH agenda; (iii) role and reiterate our commitment to be a part of such efforts at the country, responsibility of MoHs/Governments for steering the SDH action across regional and global levels. sectors and stakeholders; and (iv) “Colombo Call to Action” for actionable recommendations. During the Report Back session, the recommendations Ladies and gentlemen, were presented and ratified for adoption by all the participants. The “Colombo Call for Action” (see Annex 4) was later presented for discussion On behalf of the Regional Director and myself, I would like to wish and formal adoption. you successful deliberations and a pleasant stay in Colombo. We look forward to the outcomes and recommendations of this consultation.

4. Recommendations

(1) Health sector response to reduce health equity gap: ¾ Promote the SDH approach and actions through evidence gathering, dissemination, monitoring and advocacy, and integration of health equity in all policies. ¾ Play a stewardship role and provide leadership in bringing the various stakeholders and development partners together to address the equity gap through action on SDH. (2) Multisectoral partnerships and their response to promote action on the SDH agenda: ¾ Establish sustainable mechanisms to make the corporate sector responsive and accountable for the health of their workers, such as the establishment and enforcement of codes of conduct to promote the health of the workers. ¾ Promote multisectoral collaboration among non-governmental organizations, development partners including UN agencies, academic and research institutions, and the private sector to address SDH.

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Ladies and gentlemen, (3) Role and responsibility of Government for steering the SDH action across sectors: About 30 years ago, WHO and Member countries adopted the ¾ Establish coordination and governance mechanisms in both primary health care (PHC) approach to achieve the goal of “Health for All urban and rural settings to implement public policies to reduce by the Year 2000”. The PHC approach has remained true to its founding health inequity across population groups. principles of achieving social justice through equity in health. In August 2008, WHO and Member States revisited PHC with aim of revitalizing ¾ Provide health security through universal health coverage in primary health care concept. As is now well accepted, the underlying order to close the equity gap as envisaged in the revitalization of causes of illness and premature deaths due to food, shelter, water, primary healthcare (PHC). education, culture, environment or employment conditions, among others, ¾ Establish a coordination and management structure for cannot be addressed through vertical interventions. It is, therefore, addressing SDH such as the National SDH Commission or SDH imperative that the decisions and proposed actions from this regional Advisory Committee comprising of multisectoral players such as consultation recognize the vital role and context of the primary health care Government, civil society groups, private sector and academia. approach in addressing social determinants of health. ¾ Adopt policies or legislations that protect consumers from the I am sure these issues will be thoroughly discussed so that practical negative impact of globalization by regulating the import of actions can be formulated for countries of the South-East Asia Region to health-damaging products into the country through unfair trade. take when addressing social determinants of health. We need to think and act outside the proverbial box in order to achieve the desired goal.” There is therefore a need to: 5. Conclusion

¾ Create political commitment in order to close the health equity The proceedings of the Regional Consultation were chaired by the Health gap “through action on social determinants of health”. This shall Ministers of Bangladesh (Hon. Dr A.F.M. Ruhal Haque), Bhutan (Hon. be a priority agenda for the governments in all Member Lyonopo Zangley Dupka) and Maldives (Hon. Dr Aminath Jameel). The countries; closing session was chaired by Hon. Nimal Sripala de Silva, Minister of ¾ Use the financial global crisis as an opportunity to invest more in Healthcare and Nutrition, Sri Lanka. health, e.g. early child development and improving daily living and work conditions, in order to offer more social security and The presentations brought out a plethora of information and empowerment to vulnerable groups; experiences on how SDHs were being addressed at the community level. It also discussed the effects of climate change and the financial global crisis in ¾ Engage researchers and research institutions to identify and the context of health equity. The “Colombo Call for Action” was presented measure health inequities using a Social Determinants Health and unanimously adopted by the participants. approach in order to provide the critical evidence required by policy-makers and funding agencies to take action; ¾ Address the living conditions among urban populations arising from rapid urbanization and population ageing which has become a major determinant of health; and

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Annex-1 Annex-2 Message by Hon. Prime Minister, Sri Lanka Message from Regional Director, I am pleased to give this message at the time when the Regional WHO South-East Asia Region Conference on Social Determinants of Health will be taking place in Colombo, Sri Lanka from the 18 to 20 February 2009. The overall emphasis (delivered by Dr Poonam Khetrapal Singh, Deputy Regional of the state policy of the government of Sri Lanka has been on social justice Director) and equity, economic well-being and individual rights. The policy of the state with regards to health and social welfare has remained fairly consistent Distinguished participants, colleagues, ladies and gentlemen, and stable through the years since gaining independence despite changes of governments and political structures. The poor segments of the population I have a great pleasure in welcoming you all to this important meeting have been much benefited due to such investments. Sri Lankan policy has and to convey greetings from Dr Samlee Plianbangchang. Since Dr Samlee always regarded education and health as crucial to socioeconomic is unable to attend, I have the honour to deliver his message. development, while the concept of equity and social justice in favor of the underprivileged has also been a feature of state policy. This has resulted in “The first regional consultation” on the same theme was organized by a high literacy rate of 90.1 percent and a life expectancy at birth of 70.7 for WHO Regional Office in October 2007 also in Colombo. That was when males and 75.4 for females. There has also been a substantial investments countries of our Region resolved to examine closely the causes associated in poverty alleviation. Armed conflict that was raging for more than two with premature deaths and illness through analysis and documentation. decades in the North and East of the country has been a major constraint to As we are aware, Countries of the South-East Asia Region are facing the development of the country. There was migration and displacement of the double burden of disease (noncommunicable and communicable) and population of severely affected areas to safer places, resulting in problems also new threats to health from climate change, avian influenza and natural of food, shelter, sanitation and provision of preventive and curative disasters. There is a resurgence of age-old diseases such as malaria and healthcare. But we are confident that in the near future with the end of the tuberculosis. In addition, urban settlements and slums where the most conflict in sight we would be able to address all the social issues that were vulnerable populations live are expanding. With almost half of the brought about by the civil war and The President, Mahindra Rajapakshe has population projected to live in urban areas by 2015, countries in the envisioned in his Mahinda Chintana to develop concerted action among Region need to recognize the grave threat posed by unhealthy living and sectors that would ultimately benefit the health sector and help to build a working conditions among the urban population, and the widening gaps in healthy nation. I wish all deliberations that take place at the regional health outcomes. consultation in Colombo the very best and hope that the recommendations that would come out of it will help to further improve the circumstances in There are striking health gaps between the rich and the poor, which people grow, live, work, and age which will ultimately reduce the between rural and urban, and between the advantaged and marginalized inequities in health in our region. groups of our society. Health equity studies carried out in six countries of the Region further reveal that socioeconomic status contributes to more than 50% of inequities in skilled attendance at birth. It is also obvious from the health equity analysis results that the causes of diseases and premature deaths lie outside the realm of the health sector.

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