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Social Determinants of Health and Development Policy at Yale University

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  • Good morning. I am going to speak today about innovation and evidence in understanding and addressing social determinants of health – and the opportunity to build new synergies within the broader MDG and human rights agendas.
  • I’ve structured my remarks in three sections.First, I will recap both the progress we are now making in global health, and the significant unfinished agenda to achieve the health MDGs.Second, I will review both long-standing and emerging evidence about how social contexts influence health outcomes, as well as how different kinds of interventions can influence that social context to dramatically improve results. I will then conclude with some reflections about how we can renew our MDG efforts with a health and development paradigm that pays more attention to social determinants of health, as well as more attention to synergies among efforts addressing different MDGs.
  • Let me begin by emphasizing that we are doing a lot of things right. Child mortality is falling significantly, thanks to a combination of health technology like vaccines, health service delivery, and social change. The most influential structural changes have included improvements in water and sanitation, in nutrition, and in the socio-economic status of women. AIDS mortality climbed relentlessly over the first twenty years of the epidemic, but it finally began to turn around in 2005. We must of course give credit to the diagnostics, the drugs, and the people who deliver them. But just as important, we would not have falling AIDS mortality rates without a combination of community activism, change in trade legislation, and challenges to intellectual property norms: actions outside the health sector that led to lower prices for life-saving drugs. Some health outcomes can be achieved relatively easily through narrow, technical strategies. But most need a combination of focused approaches, health system strengthening, and attention to determinants and influences beyond the health sector itself.
  • While we are making real progress, we are also dramatically failing far too often. The health related MDG where we are most off-track is maternal mortality, and that is not a surprise. The technical fixes are complex compared to immunization or tuberculosis treatment. There are some strategies to decrease maternal mortality for home births, but dramatic decreases in maternal mortality need both increases in facility-based births, and improvements in the care available at those health facilities. These are major health system strengthening challenges.And the social factors that shape these outcomes – the status of women, caste-discrimination in India that keeps marginalized people out of clinics, malnutrition during pregnancy – have been largely ignored until relatively recently. Many of you may have read or heard about the Lancet report on maternal mortality that came out earlier this week. These data come from that report, which emphasizes that progress is now being made, albeit still too slowly. Another key message from the report is that much of our progress in recent years is linked to innovation in South Asia – in particular attention to social factors and community participation, at the same time as paying attention to the formal health system.
  • Even where we are achieving some global success, remaining and emerging challenges are enormous. Effective HIV prevention is still hampered by many factors, not least social marginalization. Our recent relative success at HIV treatment scale-up is only relative – 6 million are still in immediate need of therapy that they aren’t getting. And the problem is getting more complex as more people need second line therapy.
  • Young women in southern Africa are far more likely to be infected with HIV than young men their own age. Physiology plays a part. But so does power.
  • In Asia – as in many other parts of the world – we see a similar story where men who have sex with men, and transgender people, are disproportionately affected by HIV. Once again, physiology plays a part. But so does power, or lack thereof. If we are going to make dramatic, break-through progress in HIV prevention, we will need to address these issues of power and inclusion much more directly and systematically than we have done to date. The good news is that human rights protection and promotion for girls and women, for sexual minorities, and for other groups disproportionately affected by AIDS, contributes to multiple goals at once.
  • I’ve already referred several times to the links between social and environmental factors and health outcomes. Let me now discuss social determinants of health more directly, as well as the evidence that action on social determinants can be a ‘game changer’ that can help us break through current barriers to MDG achievement.
  • I believe that one of the great contributions of the HIV response to public health more broadly has been in its emphasis on strategic multi-sectoral action. Until the emergence of prophylaxis for opportunistic infections and then combination therapy in the mid-1990s, the health sector struggled to offer much in the response to AIDS. That helped to draw attention to prevention, and to the role of other, non-health sectors in trying to reduce both short-term risk of HIV infection and long-term vulnerability. The central insight that structural factors influence HIV epidemics has remained with us into the age of HIV treatment, and indeed it has been further refined as HIV has become stubbornly entrenched in certain populations.
  • Structural determinants and their health consequences are not just important for developing countries. The transition of the HIV epidemic in the United States from a predominately white, middle-class population to ethnic minorities and the poor underlines this point.
  • It will almost never be cost-effective or strategic to address a distal or high-level structural influence for the sake of a single disease outcome. If you are trying to prevent the spread of HIV and have to choose between male circumcision and promotion of girls education, the former may give you more of a result in the short term, per dollar invested, as measured in terms of impact on HIV incidence alone. However the latter may have multiple and longer term health and development benefits, which in addition to reduced HIV risk, might include reductions in adolescent pregnancies, smaller and healthier families, and greater opportunities to contribute to and benefit from economic and social development. So we should not be addressing key structural determinants just because of single disease outcomes. As with promoting girls education, many are important issues in and of themselves, regardless of their contribution to ill health. And many structural determinants impact multiple health conditions at the same time – so structural interventions may lead to multiple positive health outcomes. As I will discuss later, we shouldn’t fall into false dichotomies or choices. Countries can and should select an appropriate mixture of strategies that respond to their own health and development needs and resource constraints.
  • How do we move from an understanding of structural determinants or structural influences, to structural interventions that can make a difference to health outcomes? First, we need to understand and map the pathways that link a broad social phenomenon like gender inequality to a specific outcome like unprotected sex. Here are two different hypotheses about how these phenomena might be linked.Once we have identified the most likely or influential causal pathways, we then need to ask where we can intervene to make a difference. Often, a policy intervention has the advantage of broad reach at low cost, but the disadvantage that it is quite distal or distant from the actual outcome that you are trying to influence. A programme or community-based intervention often contributes more directly to an outcome, but poses challenges of scale, replicability and prioritization. In this example, a structural policy intervention might be to enshrine gender equality in laws and regulations….While a structural programme approach might be building social capital and empowerment of women through self-help groups…. As I will outline over the next few minutes, both approaches have been shown to be effective. What we need to do is mix and match strategies in response to different causal pathways, and in recognition that most of these approaches can contribute to multiple social benefits at the same time.
  • One example of the power of this approach comes from tobacco control. Decades of health promotion investment to discourage smoking made relatively little impact on tobacco use in the United States.Once the State started using ‘upstream’ or structural approaches, however, we began to see dramatic results.
  • Tuberculosis in Europe provides another powerful example. Structural factors first drove the spread of TB, with the transition from agricultural to industrial economies in the late 1700’s and early 1800s. With the population explosion in cities, overcrowding, pollution, and difficult working conditions in new factories, one in four deaths in England was due to “consumption” by 1815.But by the 1850s, TB deaths in the United Kingdom began to decline steadily, as shown in this slide. The introduction of the first effective TB treatment in 1947, and then the BCG vaccine in 1954, helped to sustain the decline, but clearly these technical fixes were not the primary solution.The decline in TB mortality in the UK over the last 150 years, once again, has been broadly attributed to changing social conditions. In this particular case, benefits came by cleaning up the negative consequences of the industrial revolution – better housing policy, workplace health and safety regulations, lower birth rates, less crowding, and better nutrition.
  • Let me now share some examples of programmatic structural interventions at the community level, or what has increasingly been called the building of social capital. I don’t have the time to explore all the nuances of social capital, including its potential negative as well as its positive impacts. What I want to emphasize is that there is now considerable evidence showing that interventions to build the right kind of social capital leads quite directly to better health outcomes in a number of key areas, including child health, mental health, substance abuse and HIV and STIs.I’ll briefly touch on four examples – three from the world of HIV, and one that came out of a river blindness programme in West Africa.
  • You are probably all familiar with the story of HIV among gay men in San Francisco in the 1980s. After a dramatic spike in new infections, HIV incidence dropped sharply and quickly. Why was there so much behavior change so quickly in this particular community? There is now a strong consensus that the same social and sexual networks that first facilitated the spread of the virus then allowed a rapid networking of saferbehaviour. Community mobilization largely sprung from the bottom-up and in parallel with AIDS prevention agencies rather than as a result of those agencies’ efforts, and community norms swiftly transformed to establish safer sex as routine. Of course, HIV incidence has begun to increase again among men who have sex with men in San Francisco, although at nowhere near the incidence of the early 1980s. There are multiple hypotheses for these increases, but it is striking that the youngest and oldest men, and the men least integrated into the gay mainstream in the city, remain the most likely to be infected.
  • Analysts also agree that Uganda’s success against HIV in the early 1990s was not the result of a single intervention.Indeed, incidence began to fall prior to widespread scaling up of condom distribution, VCT services, syndromic management of STIs and other technical and clinical prevention efforts.What happened? A climate of political openness with visible political leadership; a dynamic media and civil society movement that confronted AIDS head on; real efforts to enhance the status of women in leadership roles in the country; a reduction of civil conflict that characterized Uganda in the 1980s.In other words – the strengthening of social capital.
  • In the two examples of San Francisco and Uganda, all of us in the HIV community have tried to use retrospective analysis to understand and explain what might have happened. But there have subsequently been successful initiatives to test these hypotheses in quasi-experimental settings. One example was a multi-country study that I was personally involved in called the Frontiers Prevention Project or FPP. FPP explicitly compared two different prevention approaches, one including only biomedical and health promotion services, and the other adding a community empowerment and social capital component. FPP worked in a number of countries with several different populations, but let me share the results with MSM in Ecuador here. The quantitative results were striking – with condom use by MSM at their last sexual encounters with males and females increasing in all cases, but increasing dramatically more in the full FPP intervention sites – clearly demonstrating the added value of the community empowerment component of the intervention. Although I am not showing them here, the qualitative evaluation, measuring impact on measurable social capital – was even more impressive.
  • This reported behavioural data was reinforced with biological data.Although the prevalence of syphilis increased in both arms, the increase in the intervention arm was very modest from 6.4% to 7.6% whereas in the comparison arm syphilis prevalence increased from 5.6% to 10.6%.   
  • The final example I want to share is from TDR’s Community Directed Interventions initiative. This began as a response to river blindness, where community members were used to plan, organize and evaluate ivermectin distribution. District health staff were used to introduce the CDI concept to community members and to provide the necessary link to training, supervision and commodities.The first generation of this work was very successful, so TDR decided to design and implement a multi-country study to determine the degree to which ADDITIONAL health interventions could be added to ivermectin, while maintaining results and cost-effectiveness. This of course addresses a crucial question that is often raised when discussing community participation – how complex and multi-pronged can we get before we lose impact?
  • TDR designed a quasi-experimental, multi-country study, in which CDI districts with social capital and community participation elements were compared to ‘traditional’ delivery of the same services from health centres. CDI districts performed much better on bed nets, as well as on home management of malaria.
  • Importantly, the TDR CDI study also had a costing element, which demonstrated that not only did the community participation districts achieve better health outcomes, they did so at lower cost than the ‘classic’ health posts that focus only on service delivery.
  • There is much more literature available, but even from these brief examples, we can begin to synthesize some lessons about social capital.There are two absolutely key and consistent findings.First, social networks and community structures do make a profound difference in health outcomes, which may be positive or may be negative.Second, well designed interventions can influence community norms and social capital in a way that contributes positively to health outcomes – often while saving money in the process.
  • I don’t want to over-simplify. Structural approaches have many challenges.Understanding and mapping causal pathways is not always straightforward.These are not approaches that can easily be measured in randomized control trials.At a policy level, there can and will be legitimate debates about the appropriate role of the state in regulating or influencing private behaviour. There will also be policy tensions between health experts in health ministries, and those in other ministries who are responsible for the relevant social or economic sector. At community or programme levels, there are challenges in prioritization, standardization and replication. It is not always clear which budget or combination of budgets should be used to finance structural interventions that generate benefits across traditional Ministry lines. And most of all, structural interventions do not generate instant results – it takes time to change structural conditions, and then time again for those changes to influence health outcomes.
  • Nevertheless, there is a growing evidence base that these approaches are possible, necessary and affordable. The evidence is particularly strong in the fields of reproductive health, HIV, and maternal and newborn health. There is also growing consensus around the key features of successful structural approaches to health, as reflected in this slide.
  • Let me conclude with a few thoughts on how the evidence on social determinants and structural interventions might contribute to a new health and development paradigm for achieving the MDGs.
  • Health sector approaches remain important – with the right combination of both focused programmes and system strengthening. But we need to expand our repertoire to address structural determinants if we are really going to have a game changer. The mechanism is two-fold. In some cases, structural interventions work in synergy with traditional approaches, enabling greater uptake of health services. In other cases, structural interventions themselves are needed to address the most intractable health outcomes and populations that the health system alone cannot address.
  • The IMAGE project in rural South Africa is a perfect example of such a new paradigm. Image combined microfinance and gender and HIV training for women in rural South Africa in an attempt to address structural drivers of HIV including economic and gender inequalities. The study was rigorously evaluated as a cluster randomized trial. After 2 years, the program found positive impacts on household poverty and women’s empowerment, including a 50% reduction in levels of intimate partner violence. Among young women participating in the program, there was a decrease in HIV risk behaviours, including increased communication with partners, increased VCT and condom use.One might argue that these benefits would have been seen with microfinance by itself – so why invest in adding gender and HIV training? However a subsequent study found that microfinance alone (without the gender and HIV training), did not generate the same health and empowerment impacts.Such approaches can be integrated in practical and sustainable ways. In the case of IMAGE – the gender and HIV investments have sustained strong repayment rates for the microfinance institution, allowing the program to scale up from 500 to over 12,000 women.The key lesson of IMAGE is that simultaneous action on multiple priorities can create synergies across multiple MDGs. Not just the health MDGs – in this case, IMAGE contributed to MDGS 1, 3 and 6 at the same time.
  • We have five years to go until the 2015 deadline of the MDGs. Are we on track? As I said at the beginning of my remarks, we ARE on track in a number of areas, and we need to continue and scale up the straightforward focused programmes and health sector work that are generating important results.At the same time, we need to acknowledge our uneven progress, both across the MDGs and amongst regions and populations. We need a break-through strategy.Fortunately, we are well positioned for just such an approach. Let’s take advantage of the current debates and revisions within the global health and development assistance architecture to promote attention to such a complementary paradigm – promoting combination approaches that can deliver on multiple results at once.
  • We’re making progress, but not enough.Social factors shape health outcomes – and with multisectoral approaches, we can in turn influence those social factors in a positive way.Looking forward to 2015, we won’t achieve the MDGs by just doing more of the same. We need to more of the same, but we also need to do it for less money and with more impact. The time is now for a paradigm that emphasizes such synergies.Many thanks for your attention today.
  • I am going to draw very heavily on the findings of the Maximizing Positive Synergies Collaborative Gropu at WHO, their recent Lancet publication and related presentations.The group conducted 14 studies and reviewed 250 others. Their work is incredibly important, moving us from ideological positioning to evidence. Not surprisingly, they found that context matters, that synergies can improve with time and effort, and that it is difficult to generalize conclusions.Let’s remember why there are so many focused disease programmes – they have been shown again and again to deliver real results on key issues, such as HIV, family planning, reproductive health, immunization and ante-natal care. The WHO initiative confirmed that, and pointed out that even non-targeted services can benefit from focused disease programmes. Negative impactsBadly conceived and managed single-disease programmes can cause problems for the health work force and for health information systems, but the WHO study shows that lessons are being learned and significant synergies are being developed.Positive impactsIt’s no surprise to any of us that focused programmes have led to very large increases in official development assistance financing for health.What about the impact on domestic resources? We’ve heard anecdotes this week about how some governments, such as that of Papua New Guinea, have been reducing domestic investments given the availability of international resources, but the evidence is mixed overall. Not suprisingly, there is some evidence of misalignment between available international resources and domestic needs.The WHO study confirms the huge success of focused programmes at improving availability and affordability of key commodities, but notes that system-wide supply management has not received enough attention. Beyond the WHO study, we all know that the HIV response has changed the landscape and possibilities related to intellectual property and trade.Focused efforts are enhancing community participation, and we know from our own experience that HIV responses have significantly enhanced involvement of non-health-sector actors – other sectoral ministries, CSOs, the private sector, and so on – not just in HIV but even now in TB and malaria. Malaria and TB NGOs would not be on country CCMs and acting as major sub-recipients of GFATM projects if not for HIV.
  • While there is a trend toward health systems strengthening, there is still a considerable way to go: “a recent assessment of child survival funding priorities, which notes while 97% of grants were allocated for the design and testing of new technologies only 3% support interventions to improve the delivery of essential services. “    REFERENCE: Leroy JL, Habicht JP, Pelto G, Bertozzi SM. Current priorities in health research funding and lack of impact on the number of child deaths per year. American Journal of Public Health. 2007;97(2):219-23.
  • Another massive challenge for the HIV response, as identified by my colleague MandeepDhaliwal in a study for the Stop AIDS Campaign, is the continued misalignment of HIV prevention funding, with marginalized populations continuing to be under-served. This problem would almost certainly be exacerbated if all funding goes to system-strengthening or health sector wide approaches – pointing to the need for complementary and mutually reinforcing approaches, including multiple funding strategies. We must be especially vigilant on these issues as the Global Fund moves towards national strategy funding.
  • Transcript

    • 1. Influencing health outcomes from outside the health sector: Social Determinants, Structural Interventions & Development Policy Jeffrey O’Malley Director, HIV Practice, UNDP With Julia Kim, Brian Lutz and Paul Pronyk The Unite For Sight Global Health & Innovation 2010 Conference
    • 2. Outline Significant but uneven progress in global health Extensive and longstanding evidence that social context shapes health outcomes – and that strategic structural investments can contribute to „break through‟ progress Opportunity for a new health and development paradigm as part of renewed MDG efforts
    • 3. Progress has been made on important health outcomes Source: United Nations Millennium Development Goals Report 2009 12.6 9.0 0 5 10 15 1990 2007 Global under-5 mortality Millions 2.2 2.0 0 0.5 1 1.5 2 2.5 2005 2007 Global AIDS mortality Millions 0.75 ~0.20 0 0.5 1 1.5 2 2.5 2000 2006 Global measles mortality Millions Contributions from outside health services: • 1.6 billion people have gained access to safe water since 1990 • Cost of ARV therapy radically decreased - trade & intellectual property
    • 4. But in other areas, progress has been too slow to meet global targets 320 251 0 100 200 300 400 1990 2008 Global maternal mortality Maternal deaths per 100,000 live births Source: “Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress toward Millennium Development Goal 5,” The Lancet 2010 MDG target: 80 by 2015 •The vast majority of maternal deaths occur in developing countries, with 50% in just 6: India, Nigeria, Pakistan, Afgha nistan, Ethiopia and the DRC •Globally, we are off track to meet MDG 5; only 23 countries are on track
    • 5. Unfinished business: global „progress‟ masks regional challenges Sub-Saharan Africa 22.5 million Latin America 1.6 million Caribbean 230,000 N Africa & Middle East 380,000 Eastern Europe & Central Asia 1.6 million East Asia 800,000 S & SE Asia 4.0 million North America 1.3 million Oceania 75,000 W & C Europe 760,000 •Globally, the HIV/AIDS burden is centered in sub-Saharan Africa • New HIV infections have yet to fall in some of most heavily affected countries and have recently increased in some countries & regions. Key challenges of social marginalization. • 4 million on ARVs but 6 million in need. Rapidly approaching crisis of (lack of) access to second line therapies. Limits of current intellectual property regimes.
    • 6. Unfinished business: some groups are more vulnerable than others Gender inequalities and HIV among 15 – 24 year olds, Africa HIV prevalence among 15–24 year-old men and women, selected countries in sub-Saharan Africa, 2001–2005 0 5 10 15 20 %HIVprevalence Women Men Source: UNAIDS AIDS epidemic update, December 2005
    • 7. Unfinished business: some groups are more vulnerable than others HIV prevalence among MSM in Asian cities, 2006 - 2008 4.2 5.3 5.6 8.1 8.7 29.3 30.8 4.0 8.5 9.4 4.4 0 5 10 15 20 25 30 35 Manila Kuala Lumpur Singapore Tokyo Ho Chi Minh Vientiane Jakarta Taipei Phnom Penh Hanoi Yangon Bangkok HIV prevalence (%) MSM MSM & IDU MSM & TG 0 Source:Health Sector Response to HIV/AIDS among MSM. Report of the Consultation, 18 – 20 February 2009, Hong Kong SAR (China), WHO, WPRO, Manila, 2009; van Griensven et al, Current Opinion HIV AIDS, 2009; de Lind van Wijngaarden et al, STD, 2009
    • 8. Key concepts Significant but uneven progress in global health Extensive and longstanding evidence that social context shapes health outcomes – and that strategic structural investments can contribute to „break through‟ progress Opportunity for a new health and development paradigm as part of renewed MDG efforts
    • 9. Gender equity Economic Dev‟t and Equity Early Child Development Urban & District Devt Human Rights Employment Conditions Globalization & Trade Health Systems Health Technology Better Health Social Protection Environment & Climate Change Governance & Social Inclusion EducationGender equity Economic Dev‟t and Equity Early Child Development Social Protection Environment & Climate Change Governance & Social Inclusion Education
    • 10. Health systems & health technology alone will not adequately address intractable structural determinants of poor health Structural factors influencing HIV epidemics Impacts • Migration • Supply, demand and legal context of recreational drug use • Income inequality • Lack of social cohesion and networks (i.e., social capital) • Stigma and discrimination • Gender based violence • Gender inequality • Economic insecurity • Increased HIV vulnerability for individuals, families, dependents • Lower uptake of HIV- related services (e.g., ART, treatment for opportunistic infections)
    • 11. Structural determinants and their health consequences persist even in countries with more advanced health systems The Bronx, New York Kibera, township outside Nairobi
    • 12. Many structural determinants impact multiple health conditions at the same time Structural determinant1 contributing to Disease/ condition1 Urbanization, migration Malaria, TB, leish maniasis, plague, intestinal helminthiasis Conflict, displ acement Malaria, measles, di arrhea Climate change Cholera, schistosomia sis, vector-borne diseases (e.g., river blindness, sleeping sickness) Income inequality Avg life expectancy, infant mortality, accidents, s moking 1Not exhaustive list; examples only Sources: Pronyk P. at Columbia University,WHO, McMichael T.,Sharma VP; Farmer P., Raviglione MC, Howarth JP, Dick B., Wilkinson RG, and others Anopheles mosquito, malaria vector Woman with river blindness TB bacillus
    • 13. Gender Inequality Unprotected sex Male control over economic resources Women‟s economic dependence Inability to negotiate condom use: fear of abandonment Male Physical and Social Dominance Violence against Women Inability to negotiate condom use: fear of violence “Structural interventions”: Acting outside the health sector to influence health outcomes Graphic adapted from: Rao Gupta, 2009 Policy interventions: e.g. Gender equality legislation Programme interventions: e.g. Women‟s Self-Help Groups to build Social Capital
    • 14. Structural interventions at a policy level were critical in reducing smoking in the United States Policy intervention(s) •Advertising restrictions •Public awareness campaigns •Cigarette taxes •Anti-smoking legislation •Smoking levels dropped from 52% to 25% over past 30 years •8 cent cigarette tax alone caused 2 million adults to stop smoking and prevented 60,000 teens from starting Source: McKeown T. et al. 1975, US Centers for Disease Control 2000
    • 15. Death rate per million 500 1000 1500 2000 2500 3000 1848-53 1901 192119311941 1951 1961 1971 Introduction of Streptomycin Hypotheses for decline in TB mortality prior to chemotherapy: •Public health measures (e.g., milk pasteurization, quarantining infected individuals) •Improved housing, sanitation, nutrition Source: McKeown T. et al. 1975 Structural interventions contributed to a massive decrease in TB mortality in England and Wales prior to curative interventions
    • 16. Building social capital is increasingly recognized as a key structural approach to improve health The literature highlights several health outcomes, or their determinants, influenced by social capital • Overall mortality • Child health • Mental health • Alcohol abuse, smoking • Crime and violence • STI rates, includin g HIV Historical and recent examples from around the world highlight the importance of social capital Disease •HIV/AIDS Location (Project name) • San Francisco • Uganda • Ecuador and India (Frontier‟s Prevention Project) • 10 River blindness • 20 malaria, fever • Africa (Community Directed Interventions) 1 2 3 4 Example of social capital at work: Women mobilizing against HIV/AIDS
    • 17. Strong social networks within the San Francisco gay community were leveraged to reduce new HIV infections quickly 1 HIV infections in San Francisco gay community # Source: Pronyk P., Wohlfeiler 2002
    • 18. Social capital allowed behavioral and prevention approaches to take root in Uganda and turn the tide on HIV 2 HIV prevalence in Uganda %
    • 19. Building social capital improved condom use in MSM in Ecuador . . .3 FPP quantitative results (1) Ecuador Condom use MSM 77.0% 75.3% 72.4% 84.9% 34.5% 21.7% 35.4% 53.1% 37.0% 54.9% 77.0% 33.6% 0% 20% 40% 60% 80% 100% Comparision FPP Comparision FPP Baseline Baseline Follow-up Follow-up Last partner male Condom last female Condom last male
    • 20. . . . and decreased HIV and syphilis rates3 FPP quantitative results (2) Ecuador biomarkers MSM 10.5% 8.8% 5.6% 6.4% 10.6% 7.6% 0% 10% 20% 30% 40% 50% Comparision FPP Comparision FPP Baseline Baseline Follow-up Follow-up HIV Syphilis
    • 21. Community Directed Interventions built and leveraged social capital to empower communities in health service design and delivery 4 Began as a community directed response to river blindness Community members collectively: * Plan how, when, where and by whom ivermectin will be distributed * Discuss results and adjust approach as required District health staff * Introduce CDI concept to the community * Provide training, supervision and supplies
    • 22. Community mobilization in designing and delivering health services created synergies, improving multiple health outcomes . . . 4 31 52 57 0 10 20 30 40 50 60 70 %ofhouseholdshavingatleast1ITN Comparison districts ITN through CDI for 1 year ITN through CDI for 2 years Households with at least 1 ITN 28.6 54.9 69.4 0 10 20 30 40 50 60 70 80 %childrenwithfeverwhoreceived appropriatetreatment Comparison districts HMM through CDI for 1 year HMM through CDI for 2 years Appropriate treatment of children with fever
    • 23. . . . and lowering the costs for delivery4 First Line Health Facility Level District Level
    • 24. From these examples, we begin to understand the multiple, mutually reinforcing mechanisms by which social capital influences health • Social support – emotional, instrumental, ap praisal, informational • Social influence • Social engagement • Person-to-person contact • Access to material resources Diffusion of health information More rapid adoption of behavioural norms Communities are better self advocates Self-esteem, mutual respect May influence biological processes
    • 25. Structural approaches are not easy • Potentially unclear/indirect causal links • Don’t easily conform to experimental design and evaluation frameworks • May be seen as coercive • Require expertise outside health sector • Difficult to standardize; contextual • Diffuse benefits; take time to accrue • Generates debates about which sector / ministry should pay for programmes with multi-sector benefits • Hard to change structural conditions! Source: AIDS 2000
    • 26. But there is increasing operational evidence about how strategic structural interventions can make a difference while saving money…
    • 27. Key concepts Significant but uneven progress in global health Extensive and longstanding evidence that social context shapes health outcomes – and that strategic structural investments can contribute to „break through‟ progress Opportunity for a new health and development paradigm as part of renewed MDG efforts
    • 28. Expanded approaches reinforce health sector investments while also contributing to other MDGs Health sector approaches Expanded approaches Approach Description •Vertical disease- focused programs •Programs focused on a single/ subset of diseases or conditions (e.g., HIV, malaria, measles vaccinations) •Tend to focus on “disease” rather than “health” and emphasize “treatment” over “prevention” •Health systems strengthening •Investments to improve capacity of larger health system/sector to deliver for multiple health needs •Examples: human resources, infrastructure, referral systems, health information systems, management, supply chains •Structural interventions Source: Blankenship et al. AIDS 2000; Ford Foundation 2009 (Global Review of interventions addressing poverty, women‟s empowerment and HIV) •Alters the context (social, economic, political, environmental) in which health is produced •Examples: changing laws and policies that impede access to health services; decreasing gender-based violence; building social capital Focus, details follow
    • 29. Simultaneous action on health and development priorities improves outcomes in all areas – and positive synergies achieve breakthroughs Microfinance Gender/HIV Community + + Poverty •Food security •Expenditures •Household assets Empowerment •Self confidence •Autonomy •50% reduction in IPV HIV Risk •Communication •VCT •Condom use Multiple MDG Impacts = synergy Source: Lancet 2006
    • 30. Now is an opportune time to develop and implement integrated health and development strategies • We need to recognize the importance of and implement “combination approaches,” including strategic changes in laws and policies at national level („top down‟) and focused efforts at building social capital („bottom up‟) • We need to work across sectors where it makes sense and where synergies can be maximized • We need to look at health and development in an integrated fashion and invest in interventions that accomplish multiple health and development goals concurrently • We need to keep asking the right questions of the right people: donors, governments and technical agencies
    • 31. Thank you Significant but uneven progress in global health Extensive and longstanding evidence that social context shapes health outcomes – and that strategic structural investments can contribute to „break through‟ progress Opportunity for a new health and development paradigm as part of renewed MDG efforts
    • 32. Supplemental slides on system strengthening
    • 33. Vertical disease-focused programs have yielded impressive gains, but their impact on health systems is complex Negative systems impacts Positive systems impacts Examples •Overstretched systems resources (e.g., front line health workers, management and information systems, supply chain, etc) •Redistribution of limited resources, including human resources for health, negatively impacting other community health needs •Increase in overall official development assistance for health, though some offset by reduction in domestic commitments in some places •Improved availability and affordability of key commodities •Improved community and civil society participation •Spill-over of multisectoral approaches into other health areas Source: WHO Maximum Positive Synergies Collaborative Group
    • 34. Key global health institutions and partnerships are moving toward health systems strengthening Global Fund distributions, Rounds 2-7 % •Over 1/3 of funds go to health systems •In the most recent round 16% of funds were allocated to cross-cutting health systems proposals •The Global Fund has created flexibilities to fund national strategic plans •Launched in 2007, the International Health Partnership and related initiatives (IHP+) works to strengthen health systems in line with Paris and Accra Declarations on aid effectiveness •IHP+ currently has 46 members, consisting of partner countries, bilateral and multilateral donors and other development partners Source: WHO Maximum Positive Synergies Collaborative Group, Global Fund Round 9 funding decision report, IHP+ 20 35 45 Administration and other Health systems Commodities, pr oducts and drugs
    • 35. Emphasis on systems is not without challenges and risks Challenges Examples • Building sufficient cooperation and harmonization among donors • Ensuring alignment with country needs • Ensuring accountability and transparency in use of pooled resources • Availability of technical expertise and sound policy advice to implement large-scale sector strategies and rigorously monitor and evaluate Risks • Increased medicalization of disease and poor health, including but not limited to HIV • Decreased attention to the legal, economic and social context for marginalized groups that are most- at-risk (MARP) Source: UNGASS Country Reports – HIV prevention expenditure HIV Prevention expenditure % 96 4 Other MARPS* * Men who have sex with men, injecting drug users and sex workers Expenditures are likely less, since data are available for only 38 countries. Non-reporting countries likely spend less MARPs already receive only a small share of prevention funding

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