Social determinants of health

Transcription

1 2 Social determinants of health Introduction Health is a universal human aspiration and a basic human need. The development of society, rich or poor, can be judged by the quality of its population s health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage due to ill-health. Health equity is central to this premise. Strengthening health equity globally and within countries means going beyond contemporary concentration on the immediate causes of disease to the causes of the causes the fundamental structures of social hierarchy and the socially determined conditions these create in which people grow, live, work, and age. The time for action is now, not just because better health makes economic sense, but because it is right and just. Professor Sir Michael Marmot, Interim Statement of the Commission on Social Determinants of Health 1 Human health is determined not only by contact with the microbes and toxins that directly cause illness or by organ system failures, but also by other biological and social factors. The terms risks and determinants are often used interchangeably. The intermediate determinants of health include health services use, dietary and sanitary practices, and behavioural factors. Health inequalities arise from unequal distribution of underlying determinants, including income and assets, knowledge and literacy. They influence the intermediate risk factors, for example by constraining health-seeking behaviour. The underlying determinants of health include environment and infrastructure, which create or ameliorate direct risks or limit the ability of the poor to seek health care and practice healthy behaviour. Accessibility of health services (distance, cost, actual and perceived quality) also determines health outcomes.

2 8Chapter 2 These determinants are linked with equity in complex ways. Evidence has only recently begun to accumulate on how public policy can effectively improve the health of the poor. Given the current state of knowledge, it is more useful to present the basic data about individual risk factors and determinants in the Region than to examine their relationship to health outcomes. Intermediate risk factors, including age, sex, genetic profile and health status, are discussed in the chapters on demography, morbidity and mortality. Noncommunicable diseases (NCD), occupational health, nutrition, and environmental hazards are covered in later chapters in greater detail. This chapter discusses socioeconomic factors (income and education * ) and gender, lifestyle, human rights, food security and governance issues. Box 2.1: Concern for socioeconomic determinants of health in Viet Nam and China Poor, ethnic minorities and people in remote areas of Viet Nam are the nation s most vulnerable populations. Health indicators show large disparities by income level. Access to health services also varies with socioeconomic status and residence. The poor who are sick face a high financial burden and use less and lower-cost care. The rise in living standards, including among the poor, is accompanied by increased use of tobacco, alcohol and food consumption. Increased pollution, and poor enforcement of occupational health and safety, and traffic safety standards, pose threats to health. With decentralization of health financing, it is harder for poorer provinces to fund basic health care. Rising costs of care are unaffordable for many, but there is political pressure to invest in more technologically advanced curative services. Poverty reduction and access to health care for the poor are high priorities for the Government. Policies to reduce health gaps include targeted subsidies, investments in infrastructure, training at the grassroots level, and preventive health programmes focused on maternal and child health and infectious diseases. Along with the traditional health indicators, social health policy in China now also considers potential years of life lost, and disability-adjusted life years (DALYs). Important areas of study include health economics, urbanization and health, immunization, tuberculosis control, health insurance coverage, maternal health, the life-cycle approach, and gender and health. Analysis shows that a one-year increase in life expectancy is associated with a 4.3% increase in gross domestic product (GDP), and a 1% increase in health investment is associated with a 0.78% gain in GDP. Gender inequities in health expenditure (benefit incidence) exist in all regions but were highest in eastern China. Women are also disadvantaged in access to care and timely diagnosis. Current analysis of equity focuses on health care transition in cities, factors related to health insecurity in the regions, and the performance and responsiveness of the Chinese health system. Behavioural studies include a surveillance system for behavioural risk factors and the prevention of drug abuse, teenage pregnancies, sexually transmitted infections (STI), and accidents and injuries. Relationships between health outcomes and population, employment, poverty, education and social development are being explored. Report of the Consultation on Social Determinants of Health in the Western Pacific Region, March 2006, Beijing, China. Manila, WHO Regional Office for the Western Pacific, * Occupation is usually included with socioeconomic status, with exposure to hazards and physical and mental stress obvious determinants of health. This is discussed further in Chapter 4. Health in Asia and the Pacific

3 2.1 Income, poverty and health Socioeconomic factors determine where people and communities live, the kind of environment they inhabit, how they are treated by others, the goods and services they can provide for themselves, and what their society can provide for them. Countries and areas in the Asia Pacific Region are quite heterogeneous in terms of their level of socioeconomic development. The grouping of countries and areas in the Region according to this variable is presented in Table 2.1. Table 2.1 Classification of the 48 countries and areas in the Asia Pacific Region according to level of development, 2008 Low-income countries Bangladesh Cambodia DPR Korea India Lao PDR Mongolia Myanmar Nepal Papua New Guinea Solomon Islands Timor-Leste Viet Nam Lower middleincome countries Bhutan China Fiji Indonesia Kiribati Maldives Marshall Islands Micronesia, Federated States of Philippines Samoa Sri Lanka Thailand Upper middleincome countries American Samoa Malaysia Northern Mariana Islands Palau High-income countries Australia Brunei Darussalam French Polynesia Guam Hong Kong (China) Japan Macao (China) New Caledonia New Zealand Republic of Korea Singapore Classification not known Cook Islands Nauru Niue Pitcairn Islands Tokelau Tuvalu Wallis and Futuna Tonga Vanuatu World development report 2008: agriculture for development. Washington DC, The International Bank for Reconstruction and Development / The World Bank. Poverty, both as a social concept and as a measurable characteristic, relates to many of these socioeconomic factors. Poorer countries or areas often cannot provide adequate preventive and curative health services, and poor individuals and households cannot move from unhealthy surroundings, buy enough food or use the services that exist. Poor communities usually do not have the political power needed to get better services. In many less developed and low-income countries in the Region, health status is relatively low in terms of life expectancy and other indicators. Yet people in some poor countries have good health because they have focused resources on improving the social determinants of health education and adult literacy, water and sanitation, health promotion and food security. Good health is a result of many factors other than costly health care, although people living in most wealthy countries do enjoy long life expectancy. Infant mortality is a better indicator of health system effectiveness than life expectancy and generally decreases with increased income and health spending. Health and human development indicators for 29 countries in the Region from the United Nations Development Programme (UNDP) 2 and WHO 3 databases are shown in Table 2.2. These highlight the large differences in the Region, and indicate relationships between poverty and health. The Human Development Index (HDI) is an average of three indices of (1) a long and healthy life, as measured by life expectancy at birth; (2) knowledge, as measured by adult literacy and school enrolment; and (3) living standard, as measured by adjusted per capita income. The most developed countries in the Region have HDIs nearly double the least developed (Figure 2.1); however, many countries are improving rapidly and narrowing the gap. Social determinants of health 9

4 Fig. 2.1 Trend in Human Development Index (HDI) in five Asia Pacific Region countries 10Chapter 2 HDI Human development reports. New York, United Nations Development Programme. Health in Asia and the Pacific Japan Republic of Korea Thailand India Bangladesh Real income per capita (adjusted for purchasing power) ranges from nearly US$ in Australia and Japan to well under US$ 2000 in five countries, a ratio of about 15:1. Most of the Region s population live in large countries having real GDPs per capita under US$ High average income does not always translate into social well-being because wealth may be concentrated in the hands of a few. The Gini Index reflects inequality of income distribution, with values ranging from 24.9 for Japan, which is indicative of the lowest level of inequality, to values nearly twice as high for several poor countries such as Papua New Guinea (Table 2.2). It is interesting to note that the Gini Index is also high even for some upper-middle-income countries such as Malaysia. Whether at the level of households, communities, or the nation, poverty is a major determinant of ill-health. Nearly everywhere, health outcomes among the poor are much worse than for the wealthy. The poorer countries also have greater proportions of people living below the poverty line and vulnerable to serious health risks. The poor suffer higher rates of malaria, tuberculosis (TB) and HIV/AIDS than the well-off in the Region. Even in countries now achieving high growth rates and rising out of massive poverty, the economic gains are far from equally distributed, with subsistence-level, isolated rural communities and those living in urban slum areas hardly benefiting at all. While health care can, to some extent, address their greater burden of morbidity, the poor experience systematically lower access to health services than the non-poor. When health services are available, the costs of seeking them are often more than poor patients and households can afford, thus causing the poor to delay or disrupt treatment, and often forcing them deeper into poverty.

5 Table 2.2 Development and health indicators for 29 Asia Pacific countries, 2002 and 2003 Human GDP per Gini Life Infant Country Development capita(ppp) Index expectancy mortality (per Index US$ at birth 1000 live births) Australia Japan New Zealand Singapore Republic of Korea Brunei Darussalam Tonga Malaysia Thailand Samoa Philippines China Fiji Sri Lanka Maldives Viet Nam Indonesia Mongolia Vanuatu India Solomon Islands Myanmar Cambodia Lao PDR Bhutan Nepal Papua New Guinea Bangladesh Timor-Leste Data not available Sources: Human development report 2005: international cooperation at a crossroads: aid, trade and security in an unequal world. New York, United Nations Development Programme, Core indicators 2005: health situation in the South-East Asia and Western Pacific Regions. New Delhi and Manila, WHO Regional Offices for South-East Asia and the Western Pacific, Social determinants of health 11

6 Box 2.2: Poverty and tuberculosis 12Chapter 2 The countries of WHO s South-East Asia Region (Bangladesh, Bhutan, the Democratic People s Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste) account for 3 million new TB cases and deaths annually. Nearly 3 million people now have HIV and TB coinfection. Multidrug resistance accounts for 2% of cases overall, with a few hotspots. Poverty and TB create a vicious cycle. Poorer populations are twice as likely to have TB, three times less likely to access care for TB, four times less likely to complete TB treatment and five times more likely to incur impoverishing payments for TB care. In an effort to cope with the disease, people may decrease food intake, sell assets, borrow, withdraw children from school, leave their families or delay seeking care. There may be direct impact in the form of income loss, stigmatization and homelessness. Poor housing, overcrowding, malnutrition and risky behaviour also play important roles. Tuberculosis is the single leading cause of death among women of reproductive age. Report of the WHO Regional Consultation on Social Determinants of Health New Delhi, India, September New Delhi, WHO Regional Office for South-East Asia, In general, the poor suffer much higher child mortality than the better-off. For example, in India, Indonesia, the Philippines and Viet Nam, the under-five mortality rate among the poorest quintile of the population is three times higher compared to the richest quintile (Table 2.3). Poverty generates or reinforces social exclusion due to gender, geographical location and ethnicity. Rural populations usually have worse access to water and sanitation facilities, fewer educational opportunities and higher risk of malnutrition than urban populations. The latter have more exposure to outdoor air pollution and overcrowded, unsanitary housing in underserved slum or shantytown settlements. Urban slums (areas not zoned or adequately serviced) are growing rapidly in nearly all developing countries. Table 2.3 Health in Asia and the Pacific Under-five mortality rates (U5MR) in selected Asia Pacific countries U5MR U5MR Ratio of Country Year Poorest Richest Poor:Rich quintile quintile U5MR Bangladesh Cambodia India Indonesia Nepal Philippines Viet Nam Gwatkin D, et al. Socioeconomic differences in health, nutrition and population within developing countries: an overview. Washington DC, World Bank, High national income alone does not bring economic well-being unless it is spent efficiently on what people actually need. Judicious choice of interventions helped Sri Lanka achieve good health at low cost. 4 Secure countries can divert resources from defence to health and education. New Zealand spends more than 6% of GDP on health and as much on education, but less than 2% on the military.

7 2.2 Education and health Education is a key element of sustainable development and is perhaps one of the most important underlying determinants of health at both individual and community levels. Education reduces poverty through increased employment, and provides skills for attaining better health. Evidence points to individual and societal health benefits of basic education, particularly for girls. According to the World Bank, participatory health education for schoolchildren is one of the most timely and effective ways of promoting healthier lifestyles and averting the emerging pandemic of noncommunicable diseases among the next generation of the poor. Education not only enables women to make informed choices and adopt better health and nutrition practices, it also increases the pool of health care service providers and community educators. The health and well-being of children is influenced by the family s social, economic and educational status. At the same time, it also affects the ability of children to attend school, learn and, most importantly, to complete at least 8 to 10 years of schooling. 5 Two frequently used education indicators are adult literacy rate and the combined gross enrolment ratio (CGER). Adult literacy rate is computed as the percentage of people age 15 and older who can both read and write a short simple statement about their everyday life. On the other hand, CGER is computed by dividing the number of students enrolled in all levels of schooling (elementary, secondary and tertiary) by the total population in the official age groups corresponding to these levels. These two indicators comprise the education component of the HDI, and are used as measures of the coverage, quality and effectiveness of national educational systems. Table 2.4 shows the adult literacy rates and the combined gross enrolment ratios among 29 countries in the Region in While 17 out of 29 (58.6%) countries included in the list have adult literacy rates of at least 90%, there are 3 countries (Bangladesh, Bhutan and Nepal) where the illiterate outnumber those who are literate. There is a large variability in CGER across countries, with 2003 levels ranging from 41 in Papua New Guinea to 116 in Australia. Combined gross enrolment ratio values higher than 100 imply the enrolment of people older than school age, while very low values indicate a high proportion of the school-age group being out-of-school. In general, there is a direct relationship between these two indicators, with countries having high adult literacy rates also having high CGERS. These indicators are relevant to health since school attendance and literacy affect access to and understanding of health-related knowledge. This in turn affects health-related attitudes and practices, which are very important determinants of health status. Education is probably the most critical determinant of health for women, and for society in general, because evidence shows that the benefits of education for women and girls transcend generations. Education means women benefit through increased knowledge to protect health and seek proper health care. In addition, education for women and girls results in better health, education and welfare outcomes for children and families. Female literacy rate is a strong predictor of maternal mortality rate, shown in Figure 2.2. Educated women typically have a better understanding of health-promoting practices and improved nutrition, and are more likely to increase spacing between births, so they are also less likely to die in childbirth than are uneducated women. Estimates suggest that an extra year of education can prevent two maternal deaths per live births. 6 There is a similar relationship between female literacy and neonatal mortality due to low birth weight. Social determinants of health 13

8 14Chapter 2 Table 2.4 Health in Asia and the Pacific Adult literacy rate % Combined gross enrolment ratio Australia New Zealand Japan Samoa Republic of Korea Mongolia Maldives Hong Kong (China) Singapore Philippines Brunei Darussalam Fiji Thailand China Sri Lanka Viet Nam Myanmar Malaysia Indonesia Solomon Islands Cambodia Vanuatu Lao PDR India Timor-Leste Papua New Guinea Nepal Bhutan Bangladesh Data not available Adult literacy rates and combined gross enrolment ratios among 29 countries and areas in the Asia Pacific Region, 2003 Human development reports. New York, United Nations Development Programme. Primary school enrolment of girls is almost equal to that of boys in the Region, except in southern Asia, where only 83% of girls are enrolled, compared to 90% of boys. 7 Data on enrolment at secondary and tertiary levels reveals a narrowing gender gap, but a significant proportion of girls still drop out after primary schooling.

9 Fig. 2.2 Maternal mortality and female adult illiteracy in 14 countries in the Region 100 Female adult illiteracy (per cent) China Viet Nam Myanmar Malaysia Philippines Thailand DPR Korea Mongolia Cambodia Papua New Guinea Indonesia Solomon Islands Lao PDR Timor-Leste MMR: Deaths per live births Towards a region fit for children: an atlas for the sixth East Asia and Pacific ministerial consultation. Bangkok, UNICEF East Asia and Pacific Regional Office, Female educational level is also related to under five mortality rate, which is highest in households where mothers have no schooling. 8 Studies suggest that under-5 mortality rates may be reduced by 5% 10% with every additional year of maternal education. 9 Much of the global decline in malnutrition, 10 from 1970 to 1995 is attributable to improvements in education for women. 2.3 Lifestyle and health The Asia Pacific Region is experiencing a dramatic rise in NCD and STI (see chapters 8 and 7). Diet and physical inactivity are important risk factors, along with sexual behaviour and tobacco use. Rapid economic growth and changing lifestyle patterns, including reliance on foods rich in fat, sugar and salt, increased alcohol and tobacco use, and occupational patterns resulting in more sedentary lifestyles, are causing increasing prevalence of chronic diseases. Diet and physical activity Healthy diets and regular, adequate physical activity are major factors in the promotion and maintenance of good health throughout the entire life course. Unhealthy diets and physical inactivity are risk factors for raised blood pressure and blood glucose, abnormal blood lipids, overweight and obesity, and for major chronic diseases, such as cardiovascular diseases, cancer and diabetes. Gains in women s education accounted for 43% of the total, followed by food availability, the government s commitment to health at local and national levels, and women s relative status. Social determinants of health 15

10 16Chapter 2 As a lifestyle risk factor (as opposed to risk of undernutrition), diet is no longer an issue only for wealthier populations. The probability of obesity for low socioeconomic groups exceeds that for higher economic status groups once a country s per capita income reaches US$ Much morbidity and mortality in the Region is nutritional in origin, some of which is attributed to low fruit and vegetable intake. 12 Data on dietary consumption of energy, protein and fat for 28 countries in the Region is shown in Annex Table 2.1. Average calorie intake per day is less than 2200 kcal in Bangladesh and Cambodia, but it exceeds 3000 kcal in Australia, New Zealand and the Republic of Korea. Most of the difference is due to higher consumption of fats. Between 1979 and 2002, the percentage of calories obtained from cereals and root vegetables decreased from 78% to 60% in East and South-East Asia and from 66% to 60% in South Asia. Meat products and vegetable fats increased from 9% to 18% and 7% to 10%, respectively, in the same period. Changes in Pacific island countries were less pronounced. The possible benefits of a diet low in meat and animal fats can be seen in the Region, where hundreds of millions of people are vegetarians for religious reasons. Box 2.3: Dietary changes and health in Japan Research in Japan has identified specific negative effects of current dietary trends on health. Life expectancy in Japan s subtropical island prefecture of Okinawa is still the longest in the world, but it has been falling relative to other prefectures since the 1980s. The drop in life expectancy appears to be associated with drastic socioeconomic changes following World War II, especially the introduction of cheap canned pork products, higher incomes, lower vegetable consumption and a more sedentary lifestyle. These have resulted in increased dietary fat intake and average body weight of schoolchildren, and an increase in circulatory diseases in general. Todoriki H, Willcox DC, Willcox BJ. The effects of post-war dietary change on longevity and health in Okinawa. Okinawa journal of American studies, 2004, 1: High fat diets contribute significantly to obesity and other causes of NCD. Cooking methods now use more fats, and cheap, readily available high-fat imported food is a major dietary component of the poor. Australia, French Polynesia, Kiribati, New Caledonia, New Zealand and Samoa consume more than 100g of fat per person per day. Imports of fatty meats such as lamb breast and turkey tails contribute to health risks in many Pacific island countries. Fast food, even in some developing countries, contributes to high fat consumption. In some Pacific island countries, obesity is considered a sign of prosperity and well-being, but policy-makers are becoming aware of the burden it places on the health system. Regular physical activity can reduce premature death and disability. Worldwide, physical inactivity is estimated to cause about 10% 16% of cases of breast cancer, colon and rectal cancers and diabetes mellitus, and about 22% of ischaemic heart disease. 13 Overall, 1.9 million deaths are attributable to physical inactivity. Improvement in levels of physical activity in populations requires intersectoral action, plans with clear implementation strategies, political support and resources for physical activity programmes, and partnerships with multiple agencies and sectors. To support the WHO Global Strategy on Diet, Physical Activity and Health, the Asia Pacific Physical Activity Network (APPAN) was developed to provide current information about physical activity programmes, policy development and surveillance Health in Asia and the Pacific

11 in the Region, using a website portal. 14 The Asia Pacific Physical Activity Network has been working on a project to provide data on the prevalence and trends of physical activity participation in countries in the Asia Pacific Region. Physical activity programmes can be designed as single-risk factor interventions focusing on physical inactivity only, or multi-risk factor interventions that include other lifestyle factors (e.g. unhealthy diets, tobacco use, alcohol consumption and psychosocial stress). Several countries, including Fiji, Malaysia, Samoa, Thailand and Tonga, initiated programmes as part of the implementation of a national action plan or strategy, such as for NCD prevention and control, health promotion, or physical activity promotion in particular. Some countries set up specific committees on physical activity promotion within a leading government agency (e.g. the ministries of health, education or sport) or NGOs. Box 2.4: Physical activity research and policy in Australia The Australian Department of Health and Aging has commissioned a number of research reports, projects and surveys to better understand physical activity participation in the population, in addition to implementing intervention projects to improve health through regular physical activity. Epidemiological evidence is reasonably strong, suggesting a causal relationship between physical inactivity and the increased risk of mortality and/or incidence of coronary heart disease, non-insulin dependent diabetes mellitus and colon cancer. Research also provided evidence that physical activity can improve health and well-being, reduce the risk of some chronic diseases, and help to maintain a healthy weight. The Australian Government provides a leadership role in developing physical activity policies, and as part of this, aims to encourage participation in 30 minutes of moderate-intensity physical activity on most or all days of the week, to gain a health benefit. Sources: Healthy weight resources. Canberra, Department of Health and Aged Care. Available from: health.gov.au/internet/wcms/publishing.nsf/content/health-pubhlth-strateg-active-index.htm Stephenson J et al. The costs of illness attributable to physical inactivity in Australia, a preliminary study. Canberra, Commonwealth Department of Health and Aged Care and the Australian Sports Commission, Alcohol, drugs and tobacco Excessive alcohol use is associated with lower socioeconomic status, and contributes to high levels of hypertension and a range of physical and psychosocial pathologies as well as injuries. Heavy alcohol consumption is reported among rural Indian labourers in Malaysia. In China, 26.3% of men and 1.3% of women with less than 6 years of school reported drinking more than once a day, compared with only 7.4% of men and 0.2% of women with more than 13 years. Alcohol advertising is specifically targeted to poorer sections of the community in many Asian countries. The cost of regular heavy drinking also exacerbates poverty. High alcohol consumption is associated with difficulties in finding and gaining employment. Family and social networks are affected by alcohol dependency, and alienation from these networks can exacerbate existing health problems. High levels of alcohol consumption and other forms of substance abuse can be seen as a means of coping with social isolation and other effects of poverty, while at the same time, alcohol abuse can be a cause of poverty. Social determinants of health 17

12 18Chapter 2 The incidence of drug abuse is comparatively low in the Region. Cannabis use is high in Australia, the Federated States of Micronesia and Papua New Guinea, and somewhat less in Cambodia and the Philippines. Abuse of amphetamines, a more damaging substance, is high in the latter two countries. Opiates are abused significantly in many parts of China and South-East Asia. Illness due to tobacco use currently results in nearly 5 million deaths annually worldwide, more than those due to AIDS, drugs, homicides and accidents combined. Tobacco products kill more than 2 million people a year in the Region, accounting for 12.8% of all male and 2.7% of all female deaths. There are also clear links between tobacco use and poverty. Strong measures are needed to control the menace of tobacco because the addictive habit is promoted by the influential tobacco industry. About two thirds of men smoke in Phnom Penh, Cambodia, and in China and the Republic of Korea, and nearly half do in Japan and Malaysia. Smoking is gaining a foothold among teenagers, youth and females in the Region. In China, about a third of male and nearly 8% of female teens smoke, versus 4% of women smokers in the population. In Japan, the prevalence of smoking has risen to 10% among women, and nearly 40% of adolescent boys smoke in the Philippines. Health warnings on tobacco products are used in the Region but may not be effective because of low literacy in some countries. Most countries have banned advertisement of tobacco products in the electronic media. Tobacco taxes can have a significant effect on reducing rates of smoking while providing revenue for other health activities. Studies show that for every 10% increase in tobacco prices via taxation, tobacco consumption declines by 5% 8%, with most impact on poor smokers. 15,16 However, reducing tobacco consumption is a contested policy issue in China and other countries where taxation of tobacco is a significant revenue source. Box 2.5: Smoking cessation in Maldives Since the President of Maldives made a public appeal for tobacco control in 1982, many regulations and measures were put in place, including a total ban on tobacco advertising and smoking in many public places. A high-level intersectoral committee for tobacco control was established in The first national tobacco prevalence survey, conducted in 1997, showed that 57% of males and 29% of females were smokers. This changed significantly by 2001, when tobacco use decreased to 37.4% and 15% respectively. Since then, several islands have declared themselves tobacco-free, and all women in several other islands have stopped smoking. Multisectoral mechanisms for comprehensive tobacco control: report of a regional consultation Bangkok, 9-11 July New Delhi, WHO Regional Office for South-East Asia, According to figures of the Tobacco Free Initiative, WHO Regional Office for South-East Asia, tobacco revenue is as high as 10% 12% of total government revenue in Nepal and Sri Lanka. In Nepal, annual tobacco revenue was about US$ 48 million between 1999 and 2000; it was about US$ 270 million in Sri Lanka in In India, Indonesia and Thailand, tobacco revenue accounts for 3% of total revenue. Health in Asia and the Pacific

13 Sexual behaviour The rapid emergence of HIV and re-emergence of other STI in the Region has brought sexual behaviour into sharp focus (see section 7.2). Nearly 5% of deaths worldwide and 2% in the Region are attributable to unsafe sex (Chapter 5 Annex Table 5.12). An estimated 5 million people in the Region are living with HIV and close to 1.1 million became newly infected in 2003, among them women. The prevalence of HIV infection is rising, and the large population makes even low infection rates a matter of concern. With a prevalence of less than 0.4%, India alone has about 2.5 million people living with HIV.,17 The stigma and discrimination associated with HIV infection has severe personal consequences, and also drives the infection underground, out of reach of the health system. The risk of being infected with HIV is closely linked to gender inequality, the inability to negotiate safe sex, and in some areas HIV rates are also high among injecting drug users. 2.4 Food production and security Healthy, well-nourished people are essential for national development. More than 500 million people in Asia Pacific countries do not have enough food to meet their basic nutritional needs, over 350 million in China and India alone. Food security means access to sufficient, safe and nutritious preferred food at all times to meet the requirements of an active and healthy life (see sections 4.6 and 9.3). This basic need remains unfulfilled in many countries. The high prevalence of undernutrition in the Region (see Chapter 9) is an indicator of food insecurity. At the household level, nutritional status of family members depends on sufficient food availability, equitable distribution of food within the household, and sufficient variety, quality and safety of food. Basic good health is also necessary to receive benefit from the food consumed. Production substantially determines the availability of food, strongly affecting a population s nutritional status. Efficient distribution systems and adequate reserves are also needed to achieve food security. According to the Food and Agricultural Organization of the United Nations (FAO), per capita food production has grown 3% to 4% annually since 1990 in East and South-East Asia, but in south Asia it has decreased since Thailand and Viet Nam are the world s largest rice exporters. Food aid is primarily used as a safety net for the poor and to stabilize food grain prices and alleviate famine. Food aid to the Region has declined rapidly in recent years, especially to South Asia, and is now about 22% of the world s total food aid. 18 Bangladesh maintains a public food grain distribution system through food for work, food for education, and vulnerable group feeding and development programmes, as well as open market sales of food. Given the projected increase in world population and pressures on natural resources, the problems of hunger and food insecurity have global dimensions and are likely to persist and even increase dramatically in some regions unless concerted action is taken. Widespread rapid increases in the cost of basic foods in 2007 in China and other countries have raised awareness of this problem and have highlighted relationships between economic growth, food production, energy use and global warming. 19 This should strengthen the call for intersectoral action on nutrition, as well as other socioeconomic determinants of health. The estimate of HIV prevalence rate in India was recently reduced by nearly 100%, but it still accounts for one quarter of the cases outside sub-saharan Africa. Social determinants of health 19

14 Box 2.6: Food security in the Asia Pacific Region 20Chapter 2 Many countries in the Region have improved food production markedly, yet cannot consistently meet nutrient requirements. Rice production increased substantially in Bangladesh, but selfsufficiency is constrained by rapid population growth, traditional farming practices, limited land for agriculture production and frequent natural disasters. India has made determined efforts since the 1960s to achieve self-sufficiency and improve household food security. Average per capita energy availability currently stands at 2440 kcal per day. The prevalence of poverty is still relatively high, but targeted anti-poverty measures have reduced vulnerability to famines and maintained the status of food security. In China, per capita availability of food has increased steeply to more than 2900 kcal in 2002, but annual fluctuations and uneven distribution across regions continue to cause concern. In addition, rapid industrialization has led to competition for resources between agricultural and non-agricultural sectors. Indonesia has pursued self-sufficiency in rice since the late 1960s, and food availability has increased to around 2910 kcal per day. Household food security also improved significantly. Part of this success is due to an integrated policy of marketing interventions, introducing high yielding varieties of rice and making the required inputs available. In Cambodia, nearly 30% of the population lives below the poverty line and 30% of communities face chronic food shortages. Localized food insecurity is due to lack of crop diversification and inadequate irrigation, and the loss of productive assets due to indebtedness. Food security and nutrition have a high priority in national strategies and plans. In Viet Nam, food security improvements have mainly benefited urban and wealthier households. Among the poor, the amount of calories consumed has increased but micronutrients are lacking. Significant differences remain between rich and poor and between regions within the country. Sources: The state of food insecurity in the world Rome, Food and Agriculture Organization of the United Nations, Molini V. Food security in Vietnam during the 1990s: the empirical evidence. Tokyo, United Nations University, World Institute for Development in Economics Research, 2006 (Research paper 2006/67). 2.5 Gender and health Gender and health are related through multiple pathways. Gender roles and norms and the genderbased division of labour interact with education, employment status, income, culture, household position, age, and physical and social environments. The growing feminization of poverty has been increasingly noted. In the Asia Pacific Region, intrahousehold distribution of resources and division of responsibilities between men and women, boys and girls differ with social status and economic conditions. Gender issues in health, therefore, need to be addressed within the broader framework of poverty and social inequity. Gender is not a standalone category, but is enmeshed in social, economic and cultural situations and practices. Health in Asia and the Pacific

15 Box 2.7: The Beijing Declaration and Platform for Action (1995) The explicit recognition... of the right of all women to control all aspects of their health, in particular their own fertility, is basic to their empowerment... We are determined to... ensure equal access to and equal treatment of women and men in... health care and enhance women s sexual and reproductive health. Women have the right to enjoy the highest attainable standard of physical and mental health. The enjoyment of this right is vital to their life and well-being and their ability to participate in all areas of public and private life... Women s health involves their emotional, social and physical well-being and is determined by the social, political and economic context of their lives, as well as by biology... To attain optimal health,... equality, including the sharing of family responsibilities, development and peace are necessary conditions. Beijing Declaration. See: The Human Development Index does not consider the status and participation of women, aspects of development central to gender equity. The differentials between countries in the Region seen in two specialized indices are as wide as for the HDI. The Gender-related Development Index (GDI) incorporates an index of equality between men and women with respect to life expectancy, education and income. The Gender Empowerment Measure (GEM) reflects opportunity rather than capability. It includes dimensions of political participation and decision-making power as measured by women s share of parliamentary seats, economic participation and decision-making power. The relatively greater opportunities for women in employment, education and other spheres of life in industrialized countries are reflected in their higher levels on these indices, although there are notable exceptions. These are shown for some countries in the Region in Table 2.5, with trend data for the GEM in Annex Table 2.2. Gender as a determinant of health risk Gender inequality is a strong determinant of health. Men and women have different exposure to risk factors, and different access to health information and use of health services. These lead to unequal health outcomes, which have different social and economic consequences for women and men. For example, men are more likely than women to work in and around motor vehicles and outside near roads, and are therefore more subject to injury and death from vehicle accidents. Women are more likely to be exposed to risks such as indoor household smoke and have worse access to adequate sanitation facilities. Women are more susceptible to STI, with more serious consequences than for men, including infertility. Health and health outcomes are inseparable from how people experience the health care delivery system. Women face more serious health risks than men but have difficulty seeking care because they work longer hours and have poorer access to and control over resources. Being poor or being a woman is often a cause for being discriminated against, and may result in abuse, neglect and poor treatment, and poorly explained reasons for procedures. Service providers have been observed to rarely discuss reproductive goals with couples seeking abortion services, but rather reprimand the woman for getting pregnant. 20 In some societies there are cultural barriers to women seeking care from male providers which further restrict their access to care. See also Chapter 5 Social determinants of health 21

16 22Chapter 2 Table 2.5 Although they use primary care relatively more than men, overall women have worse access to health care. 21,22 Even in industrialized countries, women are at increased risk for receiving suboptimal care for serious illness. In Canada, women age 50 or older were less likely than older men to be admitted to the intensive care unit, to receive life-saving interventions, and more likely to die when admitted because of a critical illness. 23 In some communities, society, care providers and family place lower value on women s health and survival compared to men s. Girls may be less likely to be hospitalized than boys and more likely to die prematurely. Women who work at home and on family land may be dependent on husbands or the head of the family for mobility and the ability to access services. 24 This often results in inadequate care, nutrition and rest for women. 25 A woman in prolonged labour might not be taken to the hospital, both because the decision to do so rests with her husband and not with her, and because pain and difficulty in childbirth are seen as the natural lot of women. Health in Asia and the Pacific Gender Development Index (GDI) Gender Empowerment Measure (GEM) Australia Japan New Zealand Hong Kong (China) Republic of Korea Malaysia Thailand Philippines China Sri Lanka Fiji Viet Nam Indonesia Mongolia India Lao PDR Papua New Guinea Bangladesh Nepal Cambodia Singapore Data not available Gender-related development indexes for 21 countries and areas in the Asia Pacific Region, 2005 Human development report 2005: international cooperation at a crossroads: aid, trade and security in an unequal world. NewYork, United Nations Development Programme, 2006.

17 Health status in turn affects social and economic status. This is especially true for infertility, HIV/AIDS, STI, TB and other debilitating physical and mental diseases. Stigma, social ostracism, desertion, abandonment and domestic violence can dramatically exacerbate the already lower status of women. Women are vulnerable to different forms of violence over their life cycle. Battering, coerced pregnancy and mass rape in conflict situations are dangers to women and their unborn children. Female infanticide, differential access to food and medical care, discrimination against girls in nurturing and care, and the inability of girls to attend school have been documented. 26 Courtship violence and workplace violence, high rates of intimate partner violence, dowry abuse, honour killing, psychological abuse, sexual abuse at the workplace and other forms of sexual harassment affect the health of women. 27 More healthy years of life are lost by women than by men in the Region, the result of persisting patterns of social discrimination against women and unfulfilled responsibilities of men. This poses a challenge to policy-makers, because many of these determinants are amenable to guided changes. For example, rates of TB are generally high in South-East Asia, with higher female mortality rates compared to other regions. The stigma of TB, especially in women, causes impediments to effective treatment. 28,29 Among the reasons identified are that, given their relative status in the family, fewer women go for a sputum test and more tend not to return to the clinic to complete the test. 30 When women do seek help and start taking treatment, they are more likely than men to adhere to the treatment regimen and complete the full course. Women in the reproductive age group are often undernourished and, as for almost all other infectious diseases, for TB they also run higher risk than men of contracting the disease. The rate of progression from infection to disease is significantly higher for women of reproductive age than for men of the same age. Similar evidence exists for HIV/AIDS. Globally, women already account for 48% of infected adults. In the Region, there has been a steady spread of infection to monogamous women from their partners. Maternal and child mortality Maternal mortality rates (MMR) mirror the disparities between wealthy and poor countries more than any other measure of health. As an indicator of inequality, it also reflects women s inferior place in society, with respect to household decision-making power, access to social support, economic opportunities and health care. Countries that have paid special attention to maternal and child mortality, such as Sri Lanka, are exceptions, but in general, poorer countries have higher MMR. Maternal mortality rates per live births in the Region range from 800 in Timor-Leste and 407 in India, to 13 in Thailand and 10 in Japan. The prenatal health and nutritional status of women and their ability to access obstetrical and other health facilities are determinants of maternal and child mortality. In the least-developed countries, high maternal mortality is related to measures of poor health system responsiveness. 31 The percentage of births attended by skilled personnel is an indicator of women s access to health services, and is closely associated with low MMR. The very poor and those living in rural and remote areas have the worst access. The direct and indirect obstetrical causes of maternal death are well known, and some international programmes have had some success in reducing maternal deaths. Assuming no discrimination in nutrition and health care on the basis of gender, the probability of survival of a girl child is expected to be greater than that for a boy. However, the Region as a whole is more masculine than the rest of the world, with a population sex ratio (PSR) of (the number of males per 100 females). Japan and Australia have PSRs of 95.5 and 97.6, compared to in China, in India, in Bangladesh and in Papua New Guinea. Social determinants of health 23

18 24Chapter 2 The ratio of male to female children under age five (child sex ratio, or CSR) is also an indicator of son preference, and points to the possible prevalence of sex-selective abortion and poorer care and nutrition of girls compared to boys. The most populous countries in the Region also have high CSRs: 111 in China, 107 in India (2001), 104 in Bangladesh and Indonesia and 106 in Japan. China s high CSR is partly attributed to its one-child population policy. 2.6 Human rights, governance and civil society Human rights and health Health and human rights are closely linked. Violation or neglect of the human rights of women, men and children can have the most serious health consequences. Such violations can take the form of torture and other forms of violence, denial of food and shelter, and lack of access to health care facilities in times of distress. Vulnerability to ill-health is reduced by promoting and protecting human rights. How health delivery services are designed and positioned in society can either promote or violate people s human rights. It has been demonstrated that respect for human rights in the context of HIV/AIDS, mental illness and physical disability leads to markedly better prevention and treatment. Respect for the dignity and privacy of individuals can facilitate more sensitive and humane care. Stigmatization and discrimination thwart medical and public health efforts to heal people with disease or disability. 32 In an approach to health equity based on basic human needs, beneficiaries have no active claim to their needs being met. A human rights-based approach legitimizes those claims, giving them political and legal weight. Fulfilment of rights is an obligation of the duty-bearer, not the dispensation of a charitable or compassionate act. Most countries of the Region are parties to conventions and agreements on health and human rights, including the Convention on the Elimination of All Forms of Discrimination Against Women (1979), the Convention on the Rights of the Child (1989), the International Conference on Population and Development Cairo Programme of Action (1994), the Beijing Platform of Action (1995), the Social Summit Copenhagen Declaration (1995), the Convention on the Prohibition and Immediate Action for the Elimination of the Worst Forms of Child Labour (1999) and the Maternity Protection Convention (2000). These 33 provide for: The right to the highest attainable standard of physical and mental health, including reproductive and sexual health. Equal access to adequate health care and health-related services, regardless of sex, race or other status. The right of all children, women and men to equitable distribution of food, safe drinking water and sanitation, adequate standard of living and adequate housing and a safe and healthy environment. The right to a safe and healthy workplace, and to adequate protection for pregnant women in work proven to be harmful to them. Freedom from discrimination and discriminatory social practices, including prenatal gender selection and female infanticide. Health in Asia and the Pacific

19 The right to education and access to information relating to health, including reproductive health and family planning to enable couples and individuals to decide freely and responsibly all matters of reproduction and sexuality. The human right of the child to an environment appropriate for physical and mental development. In concrete terms, there are four major criteria by which to evaluate rights to health: (1) Availability: functioning public health and health care facilities, goods and services, as well as programmes, must be available in sufficient quantity. (2) Accessibility: health facilities, goods and services have to be accessible to everyone without discrimination, within the jurisdiction of the state party. Accessibility has four overlapping dimensions: non-discrimination, physical accessibility, economic accessibility or affordability, and information accessibility. (3) Acceptability: all health facilities, goods and services must be respectful of medical ethics and culturally appropriate, sensitive to gender and life-cycle requirements, as well as designed to respect confidentiality and improve the health status of those concerned. (4) Quality: health facilities, goods and services must be scientifically and medically appropriate and of good quality. Reducing inequalities in health is an overarching aim of all public health policies. The complexity of the causes of inequalities in health means that multisectoral action is often needed. Interventions must tackle macro-environmental factors, as well as access to health care and adverse health behaviours. Progress towards targets should be evaluated regularly to inform evidence-based policy refinements. Box 2.8: Mongolia ultisectoral work for human rights and health The Government is creating a supportive policy and legal environment through the State Public Health Policy , the Mongolia MDG Strategy , and the Health Sector Strategic Master Plan These documents emphasize the right to health, well-being and equity, and call for pro-poor, client-centred and gender-sensitive approaches. The National Public Health Council is headed by the Prime Minister. It is responsible for ensuring intersectoral cooperation in implementing health policy and developing partnerships between government, NGOs, the private sector and international organizations. The government intends the National Public Health Council to be an effective tool for addressing the social determinants of health and increasing intersectoral collaboration. Report of the Consultation on Social Determinants of Health in the Western Pacific Region, March 2006, Beijing, China. Manila, WHO Regional Office for the Western Pacific, Social justice and inclusion policies are motivated by a general concern for human rights and dignity. Improving access to employment, education, health care and other services, and preventing the social exclusion of vulnerable groups also addresses health equity and poverty. In New Zealand, a social justice-oriented policy climate agenda allowed rapid large-scale changes in the way health services interact with communities, and effective intersectoral collaboration. Specific interventions were supported by research evidence from the community level. Social determinants of health 25

20 Box 2.9: Primary health care and housing improvements in New Zealand 26Chapter 2 Life expectancy in years Health in Asia and the Pacific Addressing health inequalities is a priority for health sector planning in New Zealand as well as a key focus in overall social policy. A growing research base about Maori health fostered active discussion in academic and policy circles about health inequalities (life expectancy differentials are illustrated in the chart). Maori (SNZ) Male Maori (NZMCS) Male Maori (SNZ) Female Maori (NZMCS) Female Structural reforms of the 1980s and 1990s disproportionately affected Maori and also Pacific peoples and raised concern that the reforms had undermined the egalitarian ideal and greatly increased inequality. Primary health organizations were introduced in the late 1990s to provide health care focused on the needs and participation of the community. Data also pointed to poor housing as the cause of serious health problems in Maori neighbourhoods. A US$ 45 million housing improvement programme has benefited 5000 families in Auckland Non-Maori (SNZ) Male Non-Maori (SNZ) Female High-level Meeting on Promoting Health Equity: Evidence, Policy and Action, Phnom Penh, Cambodia, October Manila, WHO Regional Office for the Western Pacific, Civil society and health The need to involve communities in planning, implementation, monitoring and evaluation of health programmes has been recognized as essential to comprehensive primary health care. Civil society organizations include health and development NGOs, community health and development training NGOs, health policy resource groups, advocacy for the marginalized, campaigns, social movements, issue-based resource centres, and environment networks. Civil society organizations often work at the grassroots level and are able to articulate the needs and aspirations of communities, especially the poor. As attainment of health goals has become more influenced by political, legal, investment, trade, employment and social factors, civil society involvement in health has also widened to include organizations whose main mandate lies outside the health sector. For example, youth organizations not specifically set up to deal with health issues have contributed to adolescent reproductive health promotion, and groups such as trade unions, which deal mainly with economic and trade issues, have played an important role in essential medicines lobbying. Civil society action on social determinants can include participatory research, lobbying and advocacy, and service delivery. Significant advances achieved through interventions by civil society organizations include the India People s Charter for Health (2000), Asian People s Charter on HIV/AIDS (2003), India s National Right to Health Care Campaign ( ), and the Mumbai Declaration for Health for All (2004).