1. SOCIAL CHARTER IN THE AMERICAS
―From the Health Perspective ―
Dra. Sofialeticia Morales
Senior Advisor for the MDG
Coordinator of Health Promotion and Social Determinants of Health
Pan American Health Organization
Washington, D.C. October 2, 2012 1

2. The principal challenges in Health in the Americas

3. Poverty and Inequality

4. Poverty: A Multi-Dimensional Challenge
‘Poverty is pronounced deprivation in well-being, and comprises many dimensions, including low incomes and the inability to acquire the basic goods and services necessary for survival with dignity. Poverty encompasses low levels of health and education, poor access to clean water and sanitation, inadequate physical security, lack of voice, and insufficient capacity and opportunity to better one’s life. The state of poverty vary by degree within countries and regions. Poverty is multidimensional making the solution a challenge to apply as many of the causes of poverty are inter-related.’
Source: World Bank, 2010

5. Poverty's Disproportionate Impact
Poverty and inequity are two of the greatest challenges of this century
The global GDP per year, US$74 trillion, represents an average of $30 per day per person in the world
2.7 billion world-wide people live on less than $2 per day
Six out of ten of the world’s poorest people are women
Stark differences in economic opportunities explain significant health inequities between and within countries
There is a 36-year-gap in average life expectancy between Malawi and Japan
The life expectancy in Dominican Republic is 73.5 whereas in Haiti it is 62.2 –a gap of 11.3 years within the same island
Median income:
$143,500
Median income:
$58,526
Sources: Robert Wood Johnson Foundation, 2011
Source: World Health Organization, 2011

6. Access to Health Services and Social Protection Programs
II.
Access to Health Services and Social Protection Programs

7. Poverty and Access to Health Services
Social exclusion and inequity in the distribution of wealth, as well as access to basic services continues to be a priority for inclusive development in our region.
According to the World Bank, in 2010, 1 out of 5 persons lived on less than $2 dollars a day, 15% of the US population and 11 of Canada´s population lived below the poverty line (2010 US census and 2009 Canada Census).
It is worth noting the uneven progress among the countries of the region. As an example, on the island of Hispaniola life expectancy in the Dominican Republic is 73.5 years while in Haiti is 62.2
inter sectoral initiatives at the highest political level that involves the whole of government and that focus on reversing the negative effects of social determinants prove to be able to sustain the poverty reduction strategies adopted in the last 20 years. (e, g, Bolsa Familia and Oportunidades)
Source: World Bank: 2008
In 2008, Cuba had 1 physician for every 159 people, whereas Haiti had 1 physician for every 11,500 people (World Bank, 2008)
In LAC, 27% of the population is without regular access to basic health services, which equals a total of 135 million (PAHO, 2009)

8. Reducir las barreras que impiden el acceso a los servicios de salud
Barreras culturales y lingüísticas que afectan el acceso de los indígenas o afrodescendientes
Doble descriminizacion de las mujeres
Maltrato por los trabajadores salud
Etnia
Barreras múltiplas
Hombres: es menos probable que busquen servicios de atención
Mujeres: violencia de género, explotación/trafico sexual,
Tienen menos acceso a servicios e información
Sexo/género/identidad de género
Miedo al rechazo, el estigma, y la discriminación
Orientación sexual
Falta de acceso a los recursos financieros, tiempo y transporte,
Falta de información
Ingreso/clase económica/social

9. El impacto de la exclusión y discriminación acumulativa
Discapacidad
Monolingue
Indígena
Edad productiva/reproductiva
Género
Falta poder política
Analfabeta
Urbano/ Rural
Pobre

10. Target
Universal Health Coverage of Good Quality accompanied by Social Protection Models for the most vulnerable population

11. Action on the social determinants and health in all policies
III.
Action on the social determinants and health in all policies

12. Poverty and Education
Education determines employment opportunities, family income and participation in social protection programs
These factors strongly influence accessibility to health services
Evidence demonstrates that families with lower levels of education have poorer health outcomes
3.1 times higher
Source: Macro International, 2011

13. Brazil: income growth and redistribution by deciles, 1998-2007
Esta gráfica resume los dramáticos cambios en la distribución del ingreso, por deciles poblacionales, operados en el Brasil en tres trienios consecutivos. Entre 1998 y 2001, el crecimiento medio annual del ingreso per cápita fue negativo en todos los deciles de población, aunque el decil más afectado (con un decrecimiento de -1.9%) fue, precisamente, el decil más pobre de la población brasileira (denotando la regresividad de los cambios). Entre 2001 y 2004, se apreció una progresividad marcada en la redistribución del ingreso, con crecimiento positivo en los seis deciles más pobres y decrecimiento, también progresivo, en los cuatro deciles más ricos. Entre 2004 y 2007 se verificó un significativo crecimiento real del ingreso per cápita a lo largo de toda la gradiente social definida por ingreso, preservando esencialmente su progresividad (i.e., mayor crecimiento entre los más pobres).
Hailu D, Dillon SS. IPCIG & AER; OnePager July 2009;89:2
Equity in health-the backbone for the post 2015 Development Agenda

14. Age, sex & hereditary factors
Breaking the Cycle of Poverty: The Role of Social Determinants of Health
Looks at the whole picture of countries (local, national, and community) addressing the inter-related factors that impact the overall health
Encourages public policies to be evaluated and changed to improve health and well-being
Enhances the elimination of gaps in health outcomes between social groups
Allows public health professionals to look for solutions outside the health care systems to improve health
Provides a framework for countries to improve the health of people while empowering and encouraging fair opportunities across the life course
Contributes to achieving the Millennium Development Goals
Age, sex & hereditary factors

15. Brazil: distributional effect on infant mortality inequality, 1997-2008
Los dramáticos cambios operados en la distribución del ingreso poblacional, dado el rol determinante del ingreso en la salud poblacional, se ven también reflejados en cambios igualmente dramáticos en la distribución de ciertos resultados de salud. En esta lámina se analizan los cambios absolutos y relativos en la desigualdad en el riesgo de muerte infantil, en función de la gradiente social definida por ingreso, en los tres periodos analizados. El panel de la izquierda muestra las líneas de regresión de la desigualdad para 1997, 2002 y 2008, en las que se verifica una reducción sostenida y no trivial de la pendiente o inclinación de las mismas, denotando una reducción de las desigualdades en la mortalidad infantil. De hecho, el índice de desigualdad de la pendiente indica que el exceso de mortalidad infantil asociado a la desigualdad en ingreso en la sociedad brasileña se redujo de 52 muertes infantiles por 1000 nacidos vivos en 1997 a 36 en 2002 y a 23 por 1000 en el En el panel derecho se muestran las correspondientes curvas de concentración de la desigualdad y su reducción en el mismo periodo. El índice de concentración en salud se redujo de en 1997 a en el 2008; en 1997 el quintil (20%) más pobre de la sociedad brasileña acumulaba aproximadamente el 40% de todas las muertes infantiles; en 2008 esto se redujo a cerca del 30%. En resumen, la mortalidad infantil promedio mejoró en su conjunto a nivel nacional (cayó de 39 por 1000 a 21 por mil entre 1997 y 2008) y, concomitantemente, la desigualdad en la mortalidad infantil se redujo aproximadamente un 50%.
Graficas desarrolladas por Oscar Mujica

16. Target
Regional standardized national information systems in health, and vital statistics that allow the disaggregation of data by sub national level, sex, ethnicity and race as well as economic status

17. Urban Health

18. Urbanization in the Region of the Americas
The Continuing Challenge of Rapid Urbanization in the Americas
LAC is the most urbanized region in the developing world, with 77 percent of its population living in cities
Major cities in the United States (Atlanta, Washington D.C. & New York) have the highest levels of inequality in the country, similar to Abidjan, Nairobi & Santiago
In Belize, Guatemala and Peru over 50% of the urban population lives in slums, while in Barbados, Chile, Guyana, and Uruguay, less than 10% of the urban population lives in slums
Infant mortality ranges from 6.5% in one central area to 16% in another part of Greater Buenos Aires, Argentina (Bernardini, 2009)
In Bolivia, 93 per cent of children in small cities and towns are enrolled in primary education, compared with 68 per cent in the capital and other large cities, and 72 per cent in rural areas
Urbanization in the Region of the Americas
Source: UNHabitat 2009

19. The social and economic burden of NCD
IV.
The social and economic burden of NCD

20. The social and economic burden of NCDs
More than 200 million persons in the region suffer from and NCD
4.4 million people dying each year in the Region due to Non-communicable diseases accounting for 75% of all deaths throughout the region (PAHO Mortality database)
Cardiovascular disease account for 1.9 million deaths a year;
Cancer 1.1 million, diabetes 260,000
Chronic respiratory diseases 240,000.
Of these deaths, 37% are among persons under 70 years of age and
80% occur in middle and low income countries.
Region-wide Prevalence of Obesity
Source: WHO, 2008

21. The social and economic burden of NCDs
A joint study between Harvard University and the World Economic Forum estimates that if measures are not taken,
NCDs will cost middle and low income countries almost US$500,000 million per year, equivalent to 4% of its PIB.
In LAC, diabetes alone represents a cost of approximately US$65,000 million a year.
Risk factors associated with NCDs such as alcohol and tobacco, lack of physical activity and poor diet reflect behaviors that can be changed by healthy life styles through community and individual commitment and this opens an opportunity and presents a challenge since 3.4 million deaths can be prevented.
Source: WHO, 2008

22. educational gradient in obesity prevalence; The Americas, 2000-2010
A nivel regional se verifica una marcada gradiente social en la prevalencia de obesidad según escolaridad, un indicador de capital humano. Esta gradiente social opera acumulando el problema en los sectores poblacionales con mayor ventaja (i.e., más educados). Esta observación se verifica tanto en el 2000 como diez años después.
Equity in health-the backbone for the post 2015 Development Agenda

23. Target
Target: 25% reduction in premature mortality caused by the four leading NCDs (cardiovascular disease, cancer, diabetes and chronic respiratory disease)

24. V.
A new perspective for violence and injury prevention in the scenario of Humans Security

25. Violence in the Americas
Violence poses a significant threat to health and wellbeing within the Americas
Drug trade-related violence appears to be increasing in some regions
Marginalized groups are especially vulnerable to violence
It is estimated that in 2005, people died as a result of violence in the Americas
67% of these deaths were a result of interpersonal violence
Dra. Sofialeticia Morales Garza
Team Leader, Health Promotion and Social Determinants of Health
1. Demombynes, G. (2011). Drug Trafficking and Violence in Central America and Beyond. World Development Report Background Case Study.

26. Health Promotion and the Social Determinants of Violence
Health public policies to create equitable societies and healthy settings
Fostering of Community empowerment and participation in the development of health communities
Work towards gender and economic equity and the reorientation of supportive health services
Information provision, health education and life skill enhancement
Dra. Sofialeticia Morales Garza
Team Leader, Health Promotion and Social Determinants of Health

27. Violence Prevention Ecological Model
Public health policies to create equitable societies and healthy settings
Work towards gender and economic equity and the reorientation of supportive health services.
Fostering of Community empowerment and participation in the development of health communities.
Information provision, health education and life skill enhancement
Equity, Security, Democracy, Health, Development
Gender
Regional and National Level
Age
Education
Community and Interpersonal Level
Region
Ethnicity
Employment Status
Individual Level
Violence Prevention
Socio-economic Status
Dra. Sofialeticia Morales Garza
Team Leader, Health Promotion and Social Determinants of Health
CDC, 2011

28. The Problem: Typology of Violence
Self-directed:
Suicidal behavior
Self-abuse
Interpersonal Violence
Family and intimate partner violence
Community violence
Collective Violence
Social violence
Political violence
Economic violence
Family and Intimate partner violence: violence that occurs largely between family members and intimate partners, usually although no exclusively taking place in the home.
Community violence: violence between individuals who are unrelated and who may or may not know each other, generally taking place outside of the home.
Dra. Sofialeticia Morales Garza
Team Leader, Health Promotion and Social Determinants of Health
WHO. (2002). World Report on Violence and Health.

29. Global Mortality Due to Self-inflicted Violence
Dra. Sofialeticia Morales Garza
Team Leader, Health Promotion and Social Determinants of Health
WHO, 2002, The Injury Chart Book

30. Global Mortality Due to Interpersonal Violence
Interpersonal violence makes up a significant portion of global mortality.
However, violence related mortality disproportionally affects the region of the Americas in large numbers.
Dra. Sofialeticia Morales Garza
Team Leader, Health Promotion and Social Determinants of Health
WHO, 2002, The Injury Chart Book

31. Self-directed Violence
Risk factors include demographics, psychiatric, biological, social and environmental factors
Includes suicide and self-mutilation
Interventions include treatment of mental disorders, behavioral therapy, relationship approaches, community based efforts, and societal approaches.
Suicidal behavior ranges from thinking about ending one’s life to carrying out the act
Dra. Sofialeticia Morales Garza
Team Leader, Health Promotion and Social Determinants of Health
WHO. (2002). World Report on Violence and Health.

32. IPV Trends Over Time
2009 Rate: 16.96
2001 Rate: 13.1
Violence related mortality is steadily increasing over time.
By 2020, interpersonal violence is projected to become the 14th leading cause of death worldwide (16th in 1990) and the 12th leading cause of burden of disease and DALYs lost (19th in 1990).
Dra. Sofialeticia Morales Garza
Team Leader, Health Promotion and Social Determinants of Health
PAHO, 2009, Health Indicators Database

33. Top Twenty Countries with Highest Mortality Rate Due to Homicide in the Americas, 2006 (estimated per 1000 pop)
Country 
Mortality rate from homicide
GINI Coefficient
El Salvador
70.9
48.3 (2009)
Colombia
54.6
55.9 (2010)
Guatemala
33.3
Venezuela
32.9
Brazil
30.4
54.7 (2009)
Trinidad and Tobago
30.2
Anguilla
29.7
Ecuador
21.6
49.3 (2010)
Montserrat
Guyana
21.2
Puerto Rico 19
Paraguay
18.4
52.4 (2010)
Bahamas
18.2
Barbados
18.1
Nicaragua
17.9
Belize
16.4
Panama
12.7
51.9 (2010)
St Vincent and the Grenadines
11.9
Mexico
9.4
48.3 (2008)
British Virgin Islands
8.6
Dra. Sofialeticia Morales Garza
Team Leader, Health Promotion and Social Determinants of Health
PAHO, 2010, Health Information and Analysis Project; World Bank, GINI Index, 2012

34. Interpersonal Violence Mortality Rates in the Americas By Age Group, 2000
Male IPV Mortality Rates:
Americas Ages 15-29: 68.5
Globally Ages 15-29: 19.4
Americas All Ages: 34.8
Globally All Ages: 13.2
Males ages 15 to 29 years old in the Americas have the highest interpersonal violence mortality rate of any other age group both regionally and globally.
The interpersonal violence mortality rate for males living in the Americas is This is over three times as high as the average interpersonal violence mortality rate worldwide for this group, 19.4.
Dra. Sofialeticia Morales Garza
Team Leader, Health Promotion and Social Determinants of Health
WHO, 2002, The Injury Chart Book

35. Low-and middle-income countries in the Americas had mortality rates due to violence that were more than four times as high as those in high-income countries in the region in 2000.
High income countries had a lower violence based mortality rate than the worldwide average for (8.6) and low-and middle-income countries had one almost three times as high.
Dra. Sofialeticia Morales Garza
Team Leader, Health Promotion and Social Determinants of Health
WHO, 2002, The Injury Chart Book

36. Family Violence: Abuse of the Elderly
“Elder abuse is a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person” (Action on Elder Abuse UK).’
Categories of elder abuse:
Physical Abuse: the infliction of pain or injury, physical coercion, or physical or drug induced constraint
Psychological or Emotional Abuse: the infliction of mental anguish
Financial or Material Abuse: the illegal or improper exploitation or use of funds or resources of the older person
Sexual Abuse: non-consensual sexual contact of any kind with the older person
Neglect: the refusal or failure to fulfill a caregiving obligation
Dra. Sofialeticia Morales Garza
Team Leader, Health Promotion and Social Determinants of Health

37. WHO Action Points for Violence Prevention
Develop safe, stable and nurturing relationships between children and their parents/caregivers
Develop life skills in children and adolescents
Reduce the availability and harmful use of alcohol
Reduce access to guns, knives and pesticides
Promote gender equality to prevent violence against women
Change cultural and social norms that support violence
Victim identification care and support programs
Dra. Sofialeticia Morales Garza
Team Leader, Health Promotion and Social Determinants of Health
WHO, 2009, Violence Prevention: The Evidence

38. Reorientation of Health Services: Violence Prevention
Services to Break the Cycle of Violence
Screening/ Identifying victims of violence and referral to programs
Psychosocial interventions to reduce mental health problems
Protection orders, prevention from being contacted
Providing support and care programs
Strengthening the evidence base
Collaboration across sectors including public health and criminal justice sectors
Dra. Sofialeticia Morales Garza
Team Leader, Health Promotion and Social Determinants of Health

39. Target
25% reduction in mortality caused by violence.

40. IV.
Relationship between health and sustainable development without exclusion

41. urban-rural inequalities in progress towards MDG7
drinking water
sanitation
Estas gráficas de radar dejan ver rápidamente el nivel de avance hacia la cobertura total de acceso a fuentes mejoradas de agua potable y disposición de excretas tanto a nivel urbano como a nivel rural. Estas gráficas son elocuentes en la visualización de las disparidades en cuanto a agua potable y a disposición de excretas, así como entre el medio urbano y el medio rural.
Gráficas desarrolladas por Oscar Mujica 41

42. el mayor riesgo de muerte materna se concentra sistemáticamente en la población con menor acceso a agua potable
Las desigualdades en el acceso a agua y saneamiento, indicadores del ODM 7, reproducen desigualdades y gradientes muy marcadas en el riesgo de muerte materna. Este análisis ilustra dramáticamente el efecto del acceso a agua como determinante ambiental de la mortalidad materna y cómo la acción sobre aquel impacta también dramáticamente sobre ésta: entre 1990 y 2010 el marcado incremento en el acceso a agua con conexión domiciliar se acompañó no solamente de una igualmente marcada caída en la mortalidad materna (de 87 a 59 por 100,000 nacidos vivos) sino, fundamentalmente, de una marcada reducción en la desigualdad: de 171 muertes maternas en exceso por cada 100,000 nacidos vivos en 1990 a 53 muertes maternas en exceso por cada 100,000 nacidos vivos, a lo largo del gradiente social definido por acceso a agua. Aún con estas mejoras marcadas, la mortalidad materna en la Región se sigue concentrando en los cuantiles con menor acceso a agua y saneamiento.
Graficas desarrolladas por Oscar Mujica 42

43. infant mortality by quartile of access to sanitation; The Americas, 2008
Otra prueba gráfica de la gradiente de mortalidad infantil según cuartiles de acceso a saneamiento. Es importante destacar que éste análisis gráfico, como todos los presentados aqu’, ilustran únicamente el lado interpaís de las desigualdades regionales; el lado intrapaís, en estudios de caso analizados, solo multiplican el efecto determinante de desigualdad que estas gradientes sociales tienen en los resultados en salud.
Gráficas desarrolladas por Oscar Mujica

44. maternal mortality by quartile of access to water; The Americas, 2008
Y esta es la gradiente social en mortalidad materna por cuartiles de acceso a agua potable
Gráficas desarrolladas por Oscar Mujica

45. PAHO’s Core Commitment
Vision of Health in the Americas
Values of Equity and Pan-Americanism
Focus on:
Key Countries
Special Populations
Technical Priorities
Technical
Priorities
Equity
Key
Countries
PAHO
Vision
Pan-Americanism
Special Populations

46. Addressing the Causes…
In 2008, The Commision on the Social Determinants of Health launched Closing the Gap in a Generation, putting equity firmly on the global agenda
The Commission made three over-arching recommendations:
To improve daily living conditions
To tackle the inequitable distribution of power, money and resources
To measure and understand the problem and assess the impact of action

47. Institutional Initiatives

48. Health inequalities matter Social Justice Empowerment
Material
Psychosocial
political
Creating conditions for
people to lead flourishing
lives
Safety Motherhood
UN accountability Health of mother and Child
Faces, Voices and Places
Social Protection in Health

49. Health Promotion and Social Determinants of Health
Health Equity in all Policies
Good Global
Governance
Fair Financing
Early child development and education
Healthy Places
Fair Employment
Social Protection
Universal Health Care
Market
Responsibility
Health and the distribution of health is a marker of a societal wellbeing;
Implications for health and the distribution of health of economic, social and political action;
Collective action - health, education, employment, trade, transport, environment, housing, welfare…
Gender Equity
Political empowerment
– inclusion and voice

50. Mission in Action
PAHO is strongly committed to putting equity firmly on the agenda
Equity and the Social Determinants of Health are key priorities in Health Agenda for the Americas
Addressing inequities through the approach of The social determinants of health is one of the objectives in PAHO’s Strategic Plan

51. Faces, Voices and Places
To make the most neglected communities seen and heard in meeting the targets of the MDGs
Going beyond ‘the averages’: addressing the dangerous & unjust illusion resulting from averages in health statistics
Enhancing inter-sectoral action for participatory local development by working with Ministries of Health and national & local governments
The Goal of this Initiative is:

52. ROSTROS VOCES Y LUGARES de de la OPS
AVANCES
Aplicacion de los ODM y DSS en las comunidades pobres Ampliación de la Cobertura 26 países, en 50 municipalidades. Territorios Trasnacionales Trabajo inicial en el Chaco Sudamericano con miras a expandirse e inicio del trabajo en La Mosquitia. Sistematización de los procesos llevados a cabo en los países a través de los Folletos de RVL Enfoque de equidad genero y cultural, sistemas de informacion para decisiones, participacion de mujeres y hombres, monitoreo social

53. Geo-referenced Analysis of Inequity
Uses standardized census data
Regional Atlas of Sub National Vulnerability
2. From the perspective of the social determinants of health & the MDGs
3. Highlighting the most vulnerable municipalities

54. Building and Sharing Evidence
Observatories in the region opens up opportunities for training, research and monitoring, serving as dissemination points for best practices in policy by focusing on legislation, regulation, public policies and international health policy.
CARMEN NCD Policy Observatory : a platform for the network of American countries and institutions engaged in the systematic analysis of non-communicable disease (NCD) policies
Virtual Campus: A PAHO/WHO public health technical cooperation strategy serving key actors
Regional Health Observatory: An institutional resource to facilitate access to health data, statistics and information from the Region of the Americas
EQUIDAD listserv: Specialized resource serving 65,000 in 170 countries designed to disseminate information, promote communication and interdisciplinary links on Equity, Health and Human Development

55. Health Equity as a Development Outcome
Participation
Voice
Agency
Empowerment
Psychosocial
Material
Political
Daily Living Conditions
Early life
Physical and social environments
Working conditions
Social Protection
Health Care
Structural Drivers
Societal norms and values
Social Inequities
Governance and Financing
Economic Growth and Social Policy

56. Translating the Agenda into Action Requires:
Addressing Social Justice
Investing in Health and Education
Investing in tomorrow’s New Generation
Developing Equity-based Policies
Many of today’s
Policies will affect the welfare
of tomorrow’s generation, thus,
affecting inter-generational
equity
Universal coverage of health services and social protection programs for the most vulnerable Equity in itself
Is a worthy goal
due to its
Moral implications
GDP indicator that reflect social investment
Investing in Education and Health can promote
Equity and help directly and indirectly
to reduce poverty
Policies that
Promote equity
Can boost
Social cohesion
And reduce
Political conflict

57. The principal challenges make a congruent process between the MDG’s debate post 2015 and the Social Charter

58. Thank you moraless@paho.org