The document discusses a workshop on health, environment and sustainable development governance in an intersectoral context held in Rio de Janeiro in 2012. It addresses the joint approach to social and environmental determinants of health. Key points made include: - Public health leadership is needed to achieve synergies across solutions to issues like equity, risks of non-communicable diseases, and sustainable development. - Social and environmental determinants of health are the basis of the new international framework for sustainable development.

1. TALLER SOBRE GOBERNANZA DE LA SALUD, DEL AMBIENTE Y DEL DESARROLLO
SUSTENTABLE EN UN CONTEXTO INTER SECTORIAL - ISAGS
Abordaje conjunto de los determinantes sociales y ambientales de la salud.
NCDs, Social determinants and Sustainable Development: The Inherent Agenda
Dr. Luiz A. Galvão - Gerente,Desarrollo Sostenible y Salud Ambiental
Río de Janeiro, 27 Octubre, 2012

2. Relevancia de la Salud Publica como lider del
nuevo proceso global de desarrollo sostenible
Los determinantes ambientales y sociales de la
salud son la base del nuevo esquema internacional
para el desarrollo sostenible y el liderazgo de salud
publica es necesario para que exista la sinergia
necesria para implementar de forma conjunta
soluciones a varios problemas de slaud como la
equidad, los riesgos asociados a las enfermedades
no transmisibles y el desarrollo sostenible.

3. Transición Rural-Urbana en las
Américas, 1950-2010
100
80
proporción poblacional (%)
60 ALC urbano
NA urbano
ALC rural
NA rural
40
20
0
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010

4. Pirámides de población de las
subregiones principales de las Américas;
1900 - 2010

5. Ejemplos de protección social en salud
Argentina “Plan Nacer”
“Asignación Familiar por HIjo”
Brasil “Bolsa Familia”
“Programa Salud de la Familia”
Chile “Chile Solidario”
“Acceso Universal con Garantías
Explícitas” (AUGE)
Colombia “Familias en Acción”
Haiti “Servicios Obstétricos Gratuitos” (SOG)
“Servicios Infantiles Gratuitos” (SIG)
México “Seguro Popular de Salud”

6. PORTO ALEGRE COHORT, BRAZIL
Source: Bassanesi et al. Arq Bra Card 90(6) 2008
•LOWER STATUS 2.6
TIMES HIGHER RISK
OF CVD DISEASE
•Area relatively wealthy
• In productive age
group
• Cerebrovascular 3
time higher than in
USA in the younger
age group
COST TO
SOCIAL CARDIOVASCULAR LABOR &
GRADIENT UNSUSTAINABLE
CONDITION PRODUCTIVITY

7. Mexico Enfermedades cronicas atribuibles a
obesidad
Source: Estrategia de Salud Alimentaria, 2010
Para 2010, el costo
atribuible para
sobrepeso y obesidad
fue equivalente al
total de recursos del
“Seguro Popular”
para roveer aceso
universal
Las intervenciones incluidas en el cálculo son: diagnóstico y tratamiento farmacológico de diabetes mellitus tipo 2; diagnóstico y tratamiento de la neuropatía
periférica
secundaria a diabetes; diagnóstico y tratamiento farmacológico de hipertensión arterial; diagnóstico y tratamiento de la dislipidemia; diagnóstico y tratamiento de la
insuficiencia cardiaca crónica; diagnóstico y tratamiento de osteoartritis; y, diagnóstico y tratamiento de cáncer de mama.
2 Las enfermedades seleccionadas atribuibles al sobrepeso y la obesidad son: cáncer de mama; diabetes mellitus tipo 2; enfermedades cardiovasculares; y,
osteoartritis
Gradiente Enfermedades
Social Riesgos Costo al sistema Insostenible
cronicas
y familias

8. Global inequalities: energy rich, energy poor
A. Per capita
Carbon emissions
A. Health
impacts from
climate change:
higher on those
with lower
emissions
B. 2.4 billion
exposed to
pollution from
solid fuels:
B. Biomass use
health impacts
(% of all energy at
remain with the
national level)
users
Source: Wilkinson et al, Lancet 2007
Globally, the analysis shows a payback of US$ 91 billion a year from the US$ 13
billion a year invested to halve the number of people cooking with solid fuels by
providing them with access to LPG by 2015 (Source: Fuel for Life).

9. GLOBAL ESTIMATES: NCDS HARVARD WEF STUDY
ESTIMATES IN 47 TRILLION USD THE $ BURDEN
http://m.ibtimes.com/gallup-u-s-workers-86-percent-u-s-
GLOBAL ESTIMATES: GALLUP workers-have-chronic-conditions-chronic-conditions-cost-
153-billio-233376.html
Approximately 86 percent of U.S. workers
are either overweight or have chronic
health conditions that cost more than $153
billion in lost productivity each year
MEDICAL COST
SOCIAL &
GRADIENT CHRONIC DISEASES UNSUSTAINABLE
PRODUCTIVITY

10. Brasil: redistributional effect on infant mortality inequality, 1997-2008
Equity in health‐the backbone for the post 2015 Development
A d

11. maternal mortality inequalities by female years of schooling, The Americas
700 1.0
1990 2010
0.9
600
0.8
maternal mortality (x 1 0 5 live births)
500
maternal deaths (c umm %)
0.7
0.6
400
0.5
300
0.4
0.3
200
0.2
100
0.1 1990 2010
0 0.0
0 2 4 6 8 10 12 14 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
schooling (years) population gradient by years of schooling (cumm %)
health concentration index in 1990 = -
0.44
health concentration index in 2010 = -
0.27
Equity in health‐the backbone for the post 2015 Development
A d

12. concentration of social inequalities in mortality; The Americas, 2008
diabetes deaths, by gender
1.0
0.9
0.8
0.7
diabetes deaths (cum m % )
0.6
0.5
0.4
0.3
0.2 HCI males = -0.117
0.1 female male
HCI females = -0.184
0.0
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
population gradient by human development (cumm %)
Equity in health‐the backbone for the post 2015 Development
A d

13. urban-rural inequalities in progress towards MDG7
urban rural
drinking
water
sanitation
Equity in health‐the backbone for the post 2015 Development
A d

14. el mayor riesgo de muerte materna se concentra sistemáticamente en la
población con menor acceso a agua potable
líneas de regresión de la desigualdad curvas de concentración de la desigualdad
750 1.0
1990
675 2000 0.9
2010
600 0.8
mortalidad materna (tasa x 100,000 nv)
muertes maternas (% acum)
525 0.7
450 0.6
375 0.5
300 0.4
225 0.3
150 0.2
1990
75 0.1 2000
2010
0 0.0
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
gradiente social de acceso a agua con conexión domiciliar gradiente social de acceso a agua con conexión domiciliar
mortalidad materna (por 100,000 nv) 1990 2000 2010
valor promedio regional 86.66 67.31 58.92
índice de desigualdad de la pendiente (desigualdad absoluta) ‐171.75 ‐125.01 ‐52.81
índice de concentración de la desigualdad (desigualdad relativa) ‐0.42 ‐0.38 ‐0.18
Equity in health‐the backbone for the post 2015 Development
A d

15. infant mortality by quartile of access to sanitation; The Americas, 2008
24.9
25
infant mortality rate (xr 1,000 live births)
20 18.8
15
12.9
10
6.6
5
0
lowest second third highest
quartile of improved access to sanitation
Equity in health‐the backbone for the post 2015 Development
A d

16. maternal mortality by quartile of access to water; The Americas, 2008
138.6
140
maternal mortality ratio (x 1,000 live births)
120
100
88.4
80
57.9
60
40
23.2
20
0
lowest second third highest
quartile of improved access to water
Equity in health‐the backbone for the post 2015 Development
A d

17. human development inequalities in mortality; The Americas, 2008
external causes, by gender
mortality, external causes (rate x 10 pop)
female
200
179.3 male
5
160
143.6
120 109.0
106.4
86.4 73.7
80
65.5
37.1 50.8
40 31.0 28.5
23.7
0
lowest second third highest
human development quartile
Equity in health‐the backbone for the post 2015 Development
A d

18. Eventos globales de relevancia en desarrollo

19. The Future We Want

20. United Nations Conference on Sustainable Development
(UNCSD) - Rio + 20 Rio de Janeiro, Brazil, June 20-22,
2012 convened by the UNGA in 2009
• The main outcome of the Conference was the official report ‘The future we want’
• six sections:
– Our common vision;
– Renewing political commitment;
– Green economy in the context of sustainable development and poverty eradication;
– Institutional framework for sustainable development;
– Framework for action and follow‐up; and
– Means of implementation.
• nine paragraphs on health reframing the debate over sustainability in terms that focus more directly on
human well‐being:
http://www.uncsd2012.org/content/documents/727The%20Future%20We%20Want%2019%20June%201230p
m.pdf

22. “The Future we Want”
Preamble:
• We recognize that health is a precondition for, an outcome of, and an
indicator of all three dimensions of sustainable development. We
understand the goals of sustainable development can only be achieved in
the absence of a high prevalence of debilitating communicable and non‐
communicable diseases, and where populations can reach a state of
physical, mental and social well‐being. We are convinced that action on
the social and environmental determinants of health, both for the poor
and the vulnerable and the entire population, is important to create
inclusive, equitable, economically productive and healthy societies. We call
for the full realization of the right to the enjoyment of the highest
attainable standard of physical and mental health.

23. The Future We Want
Paragraphs on Health and population Chapter:
‐ Universal health coverage ‐ equitable universal coverage;
– HIV and AIDS, malaria, tuberculosis, influenza, NTDs, and polio serious global
concerns;
– Non‐communicable diseases (NCDs) challenges for sustainable development in
the 21st century: cancers, cardiovascular diseases, chronic respiratory diseases
and diabetes
– Recognize that reducing air, water and chemical pollution leads to positive
effects on health;
– Right to use Trade‐Related Aspects Intellectual Property Rights (TRIPS);
– Strengthen health systems financing, development, retention of the health
work force;
– Consider population trends and projections in development strategies and
policies;
– sexual and reproductive health and all human rights in this context;
– Reduce maternal and child mortality, improve health of women,men,youth &
children.

25. Thematic Consultations Themes
In addition to the country consultations, a number of thematic consultations are being
planned. The timeline for these is May 2012 to February 2013. We understand that
the provisional list of themes is as follows:
• Inequalities (across all dimensions, including gender)
• Health (issues covered by MDGs 4,5 and 6, and also non-communicable diseases)
• Education (primary, secondary, tertiary and vocational)
• Growth and employment (including investment in productive capacities, decent
employment and social protection)
• Environmental sustainability (including access to energy, biodiversity, climate
change and food security)
• Governance (governance at all levels; global, national and subnational)
• Conflict and fragility (conflict and post--‐conflict countries, and those prone to
natural disasters)
• Population dynamics (including ageing, international and internal migration, and
urbanisation)
• Food security and nutrition

26. Procesos para los ODS (rojo), marco de desarrollo post-2015 (azul), consultas
(naranja) Implementacion y revision de los ODMs (verde)

27. What priority themes should
SDGs address?

29. Esquema dee conceptos que serviran para definir el nuevo
marco de desarrollo global para los ODMs despues del 2015

30. A COMMON AGENDA, AND ONLY
SO MANY TO ACT ON IT

31. COMMON ELEMENTS IN THE AGENDA
PHC SDH NCDs DEVELOPMENT HEALTH
MDGs SUSTAINABLE PROMOTION
Governance /
Stewardship
Health system action
Community / social
participation
Information for
monitoring
Allignement of
stakeholders
Health in All Policies
/ Healthy Policies
Health Stewarship
Equity goal
Specific Concern for
NCDs
Require efective
Health Promotion
Impact of NCDs on
Development

32. Common Inherent elements

33. New responsibilities of Ministries
of Health, will need to include at
least:
• understand the political requirements of the
other sectors and agendas
• build the knowledge base of policy options
•Assess the comparative health consequences
of options
• create regular platforms for dialogue and work
• evaluate and monitor
Modified from Adelaide statement on HiAP, 2010

34. Position and Find the Synergies