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Social determinants of health
“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 Health1
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.
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.
Source: Report of the Consultation on Social Determinants of Health in the Western Pacific Region, 22-24 March 2006, Beijing, China. Manila, WHO Regional Office for the Western Pacific, 2006.
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
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. Table 2. 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. health promotion and food security.1 Income. however.1 Classification of the 48 countries and areas in the Asia Pacific Region according to level of development. buy enough food or use the services that exist. both as a social concept and as a measurable characteristic. Poverty. Health and human development indicators for 29 countries in the Region from the United Nations Development Programme (UNDP)2 and WHO3 databases are shown in Table 2. Good health is a result of many factors other than costly health care.1. Social determinants of health 9 . poverty and health Socioeconomic factors determine where people and communities live. as measured by life expectancy at birth. as measured by adult literacy and school enrolment. and (3) living standard. how they are treated by others. The grouping of countries and areas in the Region according to this variable is presented in Table 2. relates to many of these socioeconomic factors. as measured by adjusted per capita income. and poor individuals and households cannot move from unhealthy surroundings.2. The International Bank for Reconstruction and Development / The World Bank. the kind of environment they inhabit.1).2. many countries are improving rapidly and narrowing the gap. Countries and areas in the Asia Pacific Region are quite heterogeneous in terms of their level of socioeconomic development. Poorer countries or areas often cannot provide adequate preventive and curative health services. and indicate relationships between poverty and health. Washington DC. These highlight the large differences in the Region. The most developed countries in the Region have HDIs nearly double the least developed (Figure 2. The Human Development Index (HDI) is an average of three indices of (1) a long and healthy life. the goods and services they can provide for themselves. water and sanitation. Infant mortality is a better indicator of health system effectiveness than life expectancy and generally decreases with increased income and health spending. (2) knowledge. and what their society can provide for them. health status is relatively low in terms of life expectancy and other indicators. Federated States of Philippines Samoa Sri Lanka Thailand Tonga Vanuatu 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 Low-income countries Bangladesh Cambodia DPR Korea India Lao PDR Mongolia Myanmar Nepal Papua New Guinea Solomon Islands Timor-Leste Viet Nam Source: World development report 2008: agriculture for development. although people living in most wealthy countries do enjoy long life expectancy. 2008 Lower middleincome countries Bhutan China Fiji Indonesia Kiribati Maldives Marshall Islands Micronesia.
communities. United Nations Development Programme.3 0. health outcomes among the poor are much worse than for the wealthy. The poor suffer higher rates of malaria.9 for Japan. thus causing the poor to delay or disrupt treatment. isolated rural communities and those living in urban slum areas hardly benefiting at all. While health care can. Real income per capita (adjusted for purchasing power) ranges from nearly US$ 30 000 in Australia and Japan to well under US$ 2000 in five countries. Nearly everywhere.5 0.4 0. the poor experience systematically lower access to health services than the non-poor. When health services are available.1 Trend in Human Development Index (HDI) in five Asia Pacific Region countries Chapter 2 1.9 Republic of Korea 0. 2. It is interesting to note that the Gini Index is also high even for some upper-middle-income countries such as Malaysia. or the nation.6 India Bangladesh Thailand HDI 0. and often forcing them deeper into poverty.0 Japan 0.0 1975 1980 1985 1990 1995 2000 2003 Source: Human development reports.8 0. poverty is a major determinant of ill-health.7 0. a ratio of about 15:1. The Gini Index reflects inequality of income distribution. New York.1 0. to some extent. address their greater burden of morbidity. 10 Health in Asia and the Pacific . High average income does not always translate into social well-being because wealth may be concentrated in the hands of a few. The poorer countries also have greater proportions of people living below the poverty line and vulnerable to serious health risks. the economic gains are far from equally distributed. with values ranging from 24. Even in countries now achieving high growth rates and rising out of massive poverty.2 0. the costs of seeking them are often more than poor patients and households can afford. to values nearly twice as high for several poor countries such as Papua New Guinea (Table 2.2). Most of the Region’s population live in large countries having real GDPs per capita under US$ 5000. which is indicative of the lowest level of inequality. with subsistence-level.Fig. tuberculosis (TB) and HIV/AIDS than the well-off in the Region. Whether at the level of households.
9 78.571 0.3 68..594 0.752 0.1 61... Core indicators 2005: health situation in the South-East Asia and Western Pacific Regions.526 0. 2 078 1 759 . 46.9 36.5 64.776 0.2 Country Australia Japan New Zealand Singapore Development and health indicators for 29 Asia Pacific countries.0 .602 0.0 70–95 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 .2 60.3 61.0 35.2 .943 0. New York..866 0.5 31.2 21.3 66..933 0.Table 2.....578 0.8 . Gini Index 35.6 57.955 0. 2 490 3 361 1 850 2 944 2 892 1 753 .7 . 36..523 0..901 0.0 68.778 0. United Nations Development Programme.4 63.5 ...2 42.659 0. trade and security in an unequal world.0 59. 2002 and 2003 Human Development Index 0.4 62. 37.751 0.6 55.9 75.5 27.0 17.513 GDP per capita(PPP) US$ 29 632 27 967 22 582 24 481 17 971 .5 19. New Delhi and Manila.3 66. .3 71..0 66.3 54. 40.5 5.3 .3 9...679 0. Data not available Sources: Human development report 2005: international cooperation at a crossroads: aid.1 59.0 3.0 26.7 73..0 34..2 64. WHO Regional Offices for South-East Asia and the Western Pacific..697 0..758 0.0 69. 33.0 5..8 15.. 32.1 44.0 82.. 2005.0 51.1 70.907 0.745 0.2 43.7 50..8 62. 1 420 2 619 1 770 .5 76.3 70.2 6.. 6 992 9 512 7 595 5 854 4 321 5 003 5 880 3 778 .6 .0 65.704 0.1 71..0 23..0 30. 2005.755 0.1 67..810 0.5 68.3 30.2 68.8 95..545 0.2 8.4 37.536 0.8 6. . Social determinants of health 11 .520 0.4 81.796 0.9 31.3 2..9 78.2 24...3 29.2 .4 14. Life Infant expectancy mortality (per at birth 1000 live births) 80. 49.3 60.
malnutrition and risky behaviour also play important roles. the poor suffer much higher child mortality than the better-off. Myanmar. Bhutan.3 Gwatkin D. Maldives. Indonesia. 2005. overcrowding. withdraw children from school.1 3.4 3. New Zealand spends more than 6% of GDP on health and as much on education.3).4 Secure countries can divert resources from defence to health and education. Nearly 3 million people now have HIV and TB coinfection. Indonesia. Tuberculosis is the single leading cause of death among women of reproductive age. India. There may be direct impact in the form of income loss. Nepal. but less than 2% on the military. 15-16 September 2005. Socioeconomic differences in health. Poverty and TB create a vicious cycle. 12 Health in Asia and the Pacific . Washington DC. geographical location and ethnicity. Poor housing. nutrition and population within developing countries: an overview. Table 2. three times less likely to access care for TB. Source: Report of the WHO Regional Consultation on Social Determinants of Health New Delhi. borrow. with a few “hotspots”. the Democratic People’s Republic of Korea.5 1. For example. unsanitary housing in underserved slum or shantytown settlements. Poorer populations are twice as likely to have TB.1 3. fewer educational opportunities and higher risk of malnutrition than urban populations.Box 2. In general. the Philippines and Viet Nam. The latter have more exposure to outdoor air pollution and overcrowded. New Delhi. Judicious choice of interventions helped Sri Lanka achieve good health at low cost. stigmatization and homelessness.3 Country Bangladesh Cambodia India Indonesia Nepal Philippines Viet Nam Source: Under-five mortality rates (U5MR) in selected Asia Pacific countries Year 2004 2000 1998-1999 2002-2003 2001 2003 2002 U5MR Poorest quintile 121 155 141 77 130 66 53 U5MR Richest quintile 72 64 46 22 68 21 16 Ratio of Poor:Rich U5MR 1.7 2. 2007. people may decrease food intake. Rural populations usually have worse access to water and sanitation facilities. Sri Lanka. Multidrug resistance accounts for 2% of cases overall. in India. the under-five mortality rate among the poorest quintile of the population is three times higher compared to the richest quintile (Table 2. World Bank. India. High national income alone does not bring economic well-being unless it is spent efficiently on what people actually need. four times less likely to complete TB treatment and five times more likely to incur impoverishing payments for TB care. WHO Regional Office for South-East Asia. sell assets. Poverty generates or reinforces social exclusion due to gender. et al.2: Poverty and tuberculosis Chapter 2 The countries of WHO’s South-East Asia Region (Bangladesh. Urban slums (areas not zoned or adequately serviced) are growing rapidly in nearly all developing countries. Thailand and Timor-Leste) account for 3 million new TB cases and 600 000 deaths annually. In an effort to cope with the disease. leave their families or delay seeking care.9 3.
while very low values indicate a high proportion of the school-age group being out-of-school. CGER is computed by dividing the number of students enrolled in all levels of schooling (elementary. Education is probably the most critical determinant of health for women. These two indicators comprise the education component of the HDI. In general. Female literacy rate is a strong predictor of maternal mortality rate. “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”.4 shows the adult literacy rates and the combined gross enrolment ratios among 29 countries in the Region in 2003. and for society in general.2. secondary and tertiary) by the total population in the official age groups corresponding to these levels. Social determinants of health 13 .2. Educated women typically have a better understanding of health-promoting practices and improved nutrition. Education reduces poverty through increased employment. These indicators are relevant to health since school attendance and literacy affect access to and understanding of health-related knowledge. and are used as measures of the coverage. because evidence shows that the benefits of education for women and girls transcend generations. to complete at least 8 to 10 years of schooling. particularly for girls. While 17 out of 29 (58. On the other hand. Evidence points to individual and societal health benefits of basic education. Table 2. quality and effectiveness of national educational systems. Estimates suggest that an extra year of education can prevent two maternal deaths per 100 000 live births. education for women and girls results in better health. with 2003 levels ranging from 41 in Papua New Guinea to 116 in Australia. education and welfare outcomes for children and families. and provides skills for attaining better health. and are more likely to increase spacing between births.5 Two frequently used education indicators are adult literacy rate and the combined gross enrolment ratio (CGER). There is a large variability in CGER across countries. Education not only enables women to make informed choices and adopt better health and nutrition practices. Bhutan and Nepal) where the illiterate outnumber those who are literate. economic and educational status. it also affects the ability of children to attend school.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. with countries having high adult literacy rates also having high CGERS. shown in Figure 2. The health and well-being of children is influenced by the family’s social. there is a direct relationship between these two indicators.6%) countries included in the list have adult literacy rates of at least 90%.6 There is a similar relationship between female literacy and neonatal mortality due to low birth weight. which are very important determinants of health status. At the same time. there are 3 countries (Bangladesh. This in turn affects health-related attitudes and practices. According to the World Bank. it also increases the pool of health care service providers and community educators. learn and. Education means women benefit through increased knowledge to protect health and seek proper health care. most importantly. In addition. so they are also less likely to die in childbirth than are uneducated women. 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. Combined gross enrolment ratio values higher than 100 imply the enrolment of people older than school age.
. United Nations Development Programme. New York. where only 83% of girls are enrolled.4 Chapter 2 Adult literacy rates and combined gross enrolment ratios among 29 countries and areas in the Asia Pacific Region.7 Data on enrolment at secondary and tertiary levels reveals a narrowing gender gap.Table 2. 53 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 99 99 99 99 98 98 97 94 93 93 93 93 93 91 90 90 90 89 88 77 74 74 69 61 59 57 49 47 41 Source: Human development reports.... 14 Health in Asia and the Pacific . compared to 90% of boys. Primary school enrolment of girls is almost equal to that of boys in the Region. but a significant proportion of girls still drop out after primary schooling. except in southern Asia. 2003 Adult literacy rate % Combined gross enrolment ratio 116 106 84 71 93 74 75 74 87 82 74 73 73 69 69 64 48 71 66 52 59 58 61 60 75 41 61 .
Unhealthy diets and physical inactivity are risk factors for raised blood pressure and blood glucose. UNICEF East Asia and Pacific Regional Office. adequate physical activity are major factors in the promotion and maintenance of good health throughout the entire life course. Rapid economic growth and changing lifestyle patterns. cancer and diabetes. overweight and obesity. abnormal blood lipids. sugar and salt. Diet and physical activity Healthy diets and regular. the government’s commitment to health at local and national levels. such as cardiovascular diseases.3 Lifestyle and health The Asia Pacific Region is experiencing a dramatic rise in NCD and STI (see chapters 8 and 7). including reliance on foods rich in fat. Social determinants of health 15 . followed by food availability. increased alcohol and tobacco use.Fig. and occupational patterns resulting in more sedentary lifestyles.8 Studies suggest that under-5 mortality rates may be reduced by 5%–10% with every additional year of maternal education. 2. Diet and physical inactivity are important risk factors. Bangkok. and women’s relative status.†. † Gains in women’s education accounted for 43% of the total. which is highest in households where mothers have no schooling.2 100 Maternal mortality and female adult illiteracy in 14 countries in the Region Solomon Islands Female adult illiteracy (per cent) 80 60 Timor-Leste Cambodia 40 Lao PDR Papua New Guinea 20 China Malaysia Thailand Viet Nam Philippines Myanmar Indonesia DPR Korea Mongolia 0 100 200 300 400 500 600 700 800 MMR: Deaths per 100 000 live births Source: Towards a region fit for children: an atlas for the sixth East Asia and Pacific ministerial consultation. 2003.9 Much of the global decline in malnutrition from 1970 to 1995 is attributable to improvements in education for women. and for major chronic diseases. 10 2. Female educational level is also related to under five mortality rate. along with sexual behaviour and tobacco use. are causing increasing prevalence of chronic diseases.
political support and resources for physical activity programmes. High fat diets contribute significantly to obesity and other causes of NCD. Changes in Pacific island countries were less pronounced.13 Overall. French Polynesia. Most of the difference is due to higher consumption of fats. contributes to high fat consumption. Willcox DC. plans with clear implementation strategies. Life expectancy in Japan’s subtropical island prefecture of Okinawa is still the longest in the world. especially the introduction of cheap canned pork products. Source: Todoriki H.9 million deaths are attributable to physical inactivity. These have resulted in increased dietary fat intake and average body weight of schoolchildren.1. but policy-makers are becoming aware of the burden it places on the health system. 2004. Meat products and vegetable fats increased from 9% to 18% and 7% to 10%. Average calorie intake per day is less than 2200 kcal in Bangladesh and Cambodia. Physical Activity and Health. diet is no longer an issue only for wealthier populations. respectively. obesity is considered a sign of prosperity and well-being. Fast food. Worldwide. policy development and surveillance 16 Health in Asia and the Pacific . 1. physical inactivity is estimated to cause about 10%–16% of cases of breast cancer. Between 1979 and 2002. New Zealand and the Republic of Korea. Imports of fatty meats such as lamb breast and turkey tails contribute to health risks in many Pacific island countries. where hundreds of millions of people are vegetarians for religious reasons. The probability of obesity for low socioeconomic groups exceeds that for higher economic status groups once a country’s per capita income reaches US$ 2500. and cheap. Kiribati. Okinawa journal of American studies.Chapter 2 As a lifestyle risk factor (as opposed to risk of undernutrition). In some Pacific island countries. The drop in life expectancy appears to be associated with drastic socioeconomic changes following World War II. the Asia Pacific Physical Activity Network (APPAN) was developed to provide current information about physical activity programmes. higher incomes. The effects of post-war dietary change on longevity and health in Okinawa. even in some developing countries. lower vegetable consumption and a more sedentary lifestyle. Improvement in levels of physical activity in populations requires intersectoral action. Box 2. Regular physical activity can reduce premature death and disability.12 Data on dietary consumption of energy. The possible benefits of a diet low in meat and animal fats can be seen in the Region. but it has been falling relative to other prefectures since the 1980s. 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.11 Much morbidity and mortality in the Region is nutritional in origin. Cooking methods now use more fats. and an increase in circulatory diseases in general. some of which is attributed to low fruit and vegetable intake. but it exceeds 3000 kcal in Australia. Willcox BJ. colon and rectal cancers and diabetes mellitus. New Zealand and Samoa consume more than 100g of fat per person per day. and about 22% of ischaemic heart disease. protein and fat for 28 countries in the Region is shown in Annex Table 2. readily available high-fat imported food is a major dietary component of the poor.3: Dietary changes and health in Japan Research in Japan has identified specific negative effects of current dietary trends on health. 1:52-61. Australia. and partnerships with multiple agencies and sectors. New Caledonia. To support the WHO Global Strategy on Diet. in the same period.
in addition to implementing intervention projects to improve health through regular physical activity. or multi-risk factor interventions that include other lifestyle factors (e. Box 2. tobacco use.3% of women with less than 6 years of school reported drinking more than once a day. compared with only 7.4: Physical activity research and policy in Australia The Australian Department of Health and Aging has commissioned a number of research reports. In China. to gain a health benefit. Canberra. 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. including Fiji. projects and surveys to better understand physical activity participation in the population. Alcohol. drugs and tobacco Excessive alcohol use is associated with lower socioeconomic status.nsf/Content/health-pubhlth-strateg-active-index. Available from: health. Several countries.in the Region.htm Stephenson J et al. Malaysia. The costs of illness attributable to physical inactivity in Australia. alcohol abuse can be a cause of poverty. Epidemiological evidence is reasonably strong. The cost of regular heavy drinking also exacerbates poverty. alcohol consumption and psychosocial stress).g. The Australian Government provides a leadership role in developing physical activity policies. 26. initiated programmes as part of the implementation of a national action plan or strategy.2% of women with more than 13 years. Thailand and Tonga.4% of men and 0. aims to encourage participation in 30 minutes of moderate-intensity physical activity on most or all days of the week.au/internet/wcms/publishing.g. Samoa. health promotion. Physical activity programmes can be designed as single-risk factor interventions focusing on physical inactivity only. and as part of this. Heavy alcohol consumption is reported among rural Indian labourers in Malaysia. using a website portal. Some countries set up specific committees on physical activity promotion within a leading government agency (e. education or sport) or NGOs. non-insulin dependent diabetes mellitus and colon cancer. or physical activity promotion in particular. reduce the risk of some chronic diseases. and help to maintain a healthy weight.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. Family and social networks are affected by alcohol dependency. Canberra. the ministries of health. Department of Health and Aged Care. Commonwealth Department of Health and Aged Care and the Australian Sports Commission. and contributes to high levels of hypertension and a range of physical and psychosocial pathologies as well as injuries. Alcohol advertising is specifically targeted to poorer sections of the community in many Asian countries. suggesting a causal relationship between physical inactivity and the increased risk of mortality and/or incidence of coronary heart disease. Research also provided evidence that physical activity can improve health and well-being. a preliminary study. 2000. while at the same time. Social determinants of health 17 . High alcohol consumption is associated with difficulties in finding and gaining employment. unhealthy diets. such as for NCD prevention and control. and alienation from these networks can exacerbate existing health problems. Sources: Healthy weight resources.3% of men and 1.gov.
conducted in 1997. homicides and accidents combined. and somewhat less in Cambodia and the Philippines. and nearly half do in Japan and Malaysia.5: Smoking cessation in Maldives Since the President of Maldives made a public appeal for tobacco control in 1982.7% of all female deaths. including a total ban on tobacco advertising and smoking in many public places. tobacco consumption declines by 5%–8%. WHO Regional Office for South-East Asia. Strong measures are needed to control the menace of tobacco because the addictive habit is promoted by the influential tobacco industry. In Japan. Studies show that for every 10% increase in tobacco prices via taxation.4% and 15% respectively. Abuse of amphetamines. The first national tobacco prevalence survey.15. Indonesia and Thailand.Chapter 2 The incidence of drug abuse is comparatively low in the Region. In Nepal. several islands have declared themselves tobacco-free. it was about US$ 270 million in Sri Lanka in 1999. About two thirds of men smoke in Phnom Penh. Tobacco products kill more than 2 million people a year in the Region. is high in the latter two countries. and in China and the Republic of Korea. about a third of male and nearly 8% of female teens smoke. a more damaging substance. Source: Multisectoral mechanisms for comprehensive tobacco control: report of a regional consultation Bangkok. reducing tobacco consumption is a contested policy issue in China and other countries where taxation of tobacco is a significant revenue source. and all women in several other islands have stopped smoking. In China. New Delhi. 9-11 July 2003. the prevalence of smoking has risen to 10% among women. Tobacco taxes can have a significant effect on reducing rates of smoking while providing revenue for other health activities. Health warnings on tobacco products are used in the Region but may not be effective because of low literacy in some countries. Since then. 2003. tobacco revenue accounts for 3% of total revenue. when tobacco use decreased to 37. accounting for 12. A high-level intersectoral committee for tobacco control was established in 1996. ¥ According to figures of the Tobacco Free Initiative. 18 Health in Asia and the Pacific .8% of all male and 2. showed that 57% of males and 29% of females were smokers. Cannabis use is high in Australia. Smoking is gaining a foothold among teenagers.¥ Box 2. Most countries have banned advertisement of tobacco products in the electronic media. tobacco revenue is as high as 10%–12% of total government revenue in Nepal and Sri Lanka. WHO Regional Office for South-East Asia. the Federated States of Micronesia and Papua New Guinea. annual tobacco revenue was about US$ 48 million between 1999 and 2000. Cambodia. Opiates are abused significantly in many parts of China and South-East Asia. drugs. In India. This changed significantly by 2001. and nearly 40% of adolescent boys smoke in the Philippines.16 However. many regulations and measures were put in place. youth and females in the Region. more than those due to AIDS. versus 4% of women smokers in the population. There are also clear links between tobacco use and poverty. with most impact on poor smokers. Illness due to tobacco use currently results in nearly 5 million deaths annually worldwide.
out of reach of the health system. quality and safety of food. This basic need remains unfulfilled in many countries. over 350 million in China and India alone. but in south Asia it has decreased since 2000. and is now about 22% of the world’s total food aid. Thailand and Viet Nam are the world’s largest rice exporters. safe and nutritious preferred food at all times to meet the requirements of an active and healthy life (see sections 4.4 Food production and security Healthy. Food aid to the Region has declined rapidly in recent years. More than 500 million people in Asia Pacific countries do not have enough food to meet their basic nutritional needs. among them 194 400 women.2). equitable distribution of food within the household. With a prevalence of less than 0. Food security means access to sufficient. 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. energy use and global warming.4%. 2. food production. strongly affecting a population’s nutritional status. Production substantially determines the availability of food.19 This should strengthen the call for intersectoral action on nutrition. food for education.¤. The high prevalence of undernutrition in the Region (see Chapter 9) is an indicator of food insecurity.18 Bangladesh maintains a public food grain distribution system through food for work. Nearly 5% of deaths worldwide and 2% in the Region are attributable to unsafe sex (Chapter 5 Annex Table 5. An estimated 5 million people in the Region are living with HIV and close to 1.17 The stigma and discrimination associated with HIV infection has severe personal consequences. At the household level. ¤ The estimate of HIV prevalence rate in India was recently reduced by nearly 100%. especially to South Asia. Given the projected increase in world population and pressures on natural resources. Efficient distribution systems and adequate reserves are also needed to achieve food security. the inability to negotiate safe sex. as well as open market sales of food. and sufficient variety. and vulnerable group feeding and development programmes.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. well-nourished people are essential for national development. and in some areas HIV rates are also high among injecting drug users. and also drives the infection underground. but it still accounts for one quarter of the cases outside sub-Saharan Africa.6 and 9.1 million became newly infected in 2003. The risk of being infected with HIV is closely linked to gender inequality. nutritional status of family members depends on sufficient food availability. India alone has about 2. Basic good health is also necessary to receive benefit from the food consumed. 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. and the large population makes even low infection rates a matter of concern.3). Social determinants of health 19 . The prevalence of HIV infection is rising. per capita food production has grown 3% to 4% annually since 1990 in East and South-East Asia. According to the Food and Agricultural Organization of the United Nations (FAO).12).5 million people living with HIV. as well as other socioeconomic determinants of health. Food aid is primarily used as a safety net for the poor and to stabilize food grain prices and alleviate famine.
but targeted anti-poverty measures have reduced vulnerability to famines and maintained the status of food security. household position. India has made determined efforts since the 1960s to achieve self-sufficiency and improve household food security. Molini V. 2. Indonesia has pursued self-sufficiency in rice since the late 1960s. and the loss of productive assets due to indebtedness. Significant differences remain between rich and poor and between regions within the country. Food security in Vietnam during the 1990s: the empirical evidence. the amount of calories consumed has increased but micronutrients are lacking. Rome. need to be addressed within the broader framework of poverty and social inequity.Box 2. 20 Health in Asia and the Pacific . limited land for agriculture production and frequent natural disasters. Among the poor. Food security and nutrition have a high priority in national strategies and plans. In addition. World Institute for Development in Economics Research. Gender is not a “standalone” category. Localized food insecurity is due to lack of crop diversification and inadequate irrigation. Part of this success is due to an integrated policy of marketing interventions. In Cambodia. Average per capita energy availability currently stands at 2440 kcal per day. yet cannot consistently meet nutrient requirements. but is enmeshed in social. In the Asia Pacific Region. but annual fluctuations and uneven distribution across regions continue to cause concern. but selfsufficiency is constrained by rapid population growth. 2006 (Research paper 2006/67). Gender issues in health. and food availability has increased to around 2910 kcal per day. employment status. culture. United Nations University. Gender roles and norms and the genderbased division of labour interact with education.6: Food security in the Asia Pacific Region Chapter 2 Many countries in the Region have improved food production markedly. nearly 30% of the population lives below the poverty line and 30% of communities face chronic food shortages. economic and cultural situations and practices. boys and girls differ with social status and economic conditions. age. In Viet Nam. income. In China. Tokyo. therefore. Sources: The state of food insecurity in the world 2004. Food and Agriculture Organization of the United Nations. Rice production increased substantially in Bangladesh. Household food security also improved significantly. 2004. intrahousehold distribution of resources and division of responsibilities between men and women. The prevalence of poverty is still relatively high. The growing feminization of poverty has been increasingly noted. introducing high yielding varieties of rice and making the required inputs available. rapid industrialization has led to competition for resources between agricultural and non-agricultural sectors. food security improvements have mainly benefited urban and wealthier households. traditional farming practices. and physical and social environments.5 Gender and health Gender and health are related through multiple pathways. per capita availability of food has increased steeply to more than 2900 kcal in 2002.
Service providers have been observed to rarely discuss reproductive goals with couples seeking abortion services. These lead to unequal health outcomes. The relatively greater opportunities for women in employment. ensure equal access to and equal treatment of women and men in .. Women are more likely to be exposed to risks such as indoor household smoke and have worse access to adequate sanitation facilities. is basic to their empowerment...20 In some societies there are cultural barriers to women seeking care from male providers which further restrict their access to care. men are more likely than women to work in and around motor vehicles and outside near roads.. economic participation and decision-making power. education and income..htm The Human Development Index does not consider the status and participation of women.5. Women’s health involves their emotional. and different access to health information and use of health services... equality. 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.7: The Beijing Declaration and Platform for Action (1995) “The explicit recognition . which have different social and economic consequences for women and men.. although there are notable exceptions. Being poor or being a woman is often a cause for being discriminated against. but rather reprimand the woman for getting pregnant. . The Gender-related Development Index (GDI) incorporates an index of equality between men and women with respect to life expectancy. with trend data for the GEM in Annex Table 2. and are therefore more subject to injury and death from vehicle accidents. “Women have the right to enjoy the highest attainable standard of physical and mental health.” Source: Beijing Declaration. 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.. We are determined to . The differentials between countries in the Region seen in two specialized indices are as wide as for the HDI.Box 2. in particular their own fertility. education and other spheres of life in industrialized countries are reflected in their higher levels on these indices. with more serious consequences than for men. development and peace are necessary conditions. These are shown for some countries in the Region in Table 2. including infertility.un. and may result in abuse. ¥ See also Chapter 5 Social determinants of health 21 . health care and enhance women’s sexual and reproductive health”.. Men and women have different exposure to risk factors.org/womenwatch/daw/beijing/platform/declar. To attain optimal health.. Health and health outcomes are inseparable from how people experience the health care delivery system. For example. neglect and poor treatment. and poorly explained reasons for procedures. social and physical well-being and is determined by the social.. of the right of all women to control all aspects of their health. aspects of development central to gender equity. including the sharing of family responsibilities. It includes dimensions of political participation and decision-making power as measured by women’s share of parliamentary seats. as well as by biology. political and economic context of their lives. Gender as a determinant of health risk¥ Gender inequality is a strong determinant of health. See: http://www... The Gender Empowerment Measure (GEM) reflects opportunity rather than capability.... Women are more susceptible to STI.2.
502 0.218 .540 0. 0..755 0.912 0. Girls may be less likely to be hospitalized than boys and more likely to die prematurely..526 .. and more likely to die when admitted because of a critical illness. .774 0.370 0.. 0.. 2005 Gender Development Index (GDI) Gender Empowerment Measure (GEM) 0. In Canada.691 0. 0.791 0. . NewYork. and because pain and difficulty in childbirth are seen as the natural lot of women. United Nations Development Programme.. society.. Human development report 2005: international cooperation at a crossroads: aid.364 0.. Although they use primary care relatively more than men.23 In some communities.388 .654 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 . trade and security in an unequal world.929 0.5 Chapter 2 Gender-related development indexes for 21 countries and areas in the Asia Pacific Region. overall women have worse access to health care....21.479 0.22 Even in industrialized countries.754 0.747 0. care providers and family place lower value on women’s health and survival compared to men’s.826 0.514 0...937 0.25 A woman in prolonged labour might not be taken to the hospital.586 0.742 0.896 0.Table 2.. 0... women age 50 or older were less likely than older men to be admitted to the intensive care unit.511 . women are at increased risk for receiving suboptimal care for serious illness. 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.534 0. 22 Health in Asia and the Pacific . Data not available Source: 0.518 0... both because the decision to do so rests with her husband and not with her...24 This often results in inadequate care...677 0.702 0. 2006. to receive life-saving interventions. .381 .954 0. .769 . 0. nutrition and rest for women.452 0.
the probability of survival of a girl child is expected to be greater than that for a boy. they are more likely than men to adhere to the treatment regimen and complete the full course. and the inability of girls to attend school have been documented. 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. Globally. desertion. 104. Japan and Australia have PSRs of 95. Maternal mortality rates per 100 000 live births in the Region range from 800 in Timor-Leste and 407 in India. honour killing. However. with respect to household decision-making power. Women are vulnerable to different forms of violence over their life cycle. as for almost all other infectious diseases. high rates of intimate partner violence.6. poorer countries have higher MMR.30 When women do seek help and start taking treatment.2 in India. coerced pregnancy and mass rape in conflict situations are dangers to women and their unborn children. and some international programmes have had some success in reducing maternal deaths. Female infanticide. HIV/AIDS. The stigma of TB. abandonment and domestic violence can dramatically exacerbate the already lower status of women.5 in Bangladesh and 106. psychological abuse. especially in women. are exceptions. Countries that have paid special attention to maternal and child mortality. given their relative status in the family. Battering. the result of persisting patterns of social discrimination against women and unfulfilled responsibilities of men. differential access to food and medical care. The rate of progression from infection to disease is significantly higher for women of reproductive age than for men of the same age. In the least-developed countries. with a population sex ratio (PSR) of 103. STI.29 Among the reasons identified are that.4 in Papua New Guinea. 105. Social determinants of health 23 . access to social support. economic opportunities and health care. social ostracism. compared to 105. fewer women go for a sputum test and more tend not to return to the clinic to complete the test. the Region as a whole is more masculine than the rest of the world.5 in China. The very poor and those living in rural and remote areas have the worst access. TB and other debilitating physical and mental diseases. it also reflects women’s inferior place in society. such as Sri Lanka. sexual abuse at the workplace and other forms of sexual harassment affect the health of women. with higher female mortality rates compared to other regions. For example.Health status in turn affects social and economic status. Stigma. In the Region.5 and 97. there has been a steady spread of infection to monogamous women from their partners. discrimination against girls in nurturing and care. Women in the reproductive age group are often undernourished and. to 13 in Thailand and 10 in Japan. This is especially true for infertility.7 (the number of males per 100 females). for TB they also run higher risk than men of contracting the disease. As an indicator of inequality. because many of these determinants are amenable to guided changes. high maternal mortality is related to measures of poor health system responsiveness. Maternal and child mortality Maternal mortality rates (MMR) mirror the disparities between wealthy and poor countries more than any other measure of health. and is closely associated with low MMR.27 More healthy years of life are lost by women than by men in the Region.28. The direct and indirect obstetrical causes of maternal death are well known.31 The percentage of births attended by skilled personnel is an indicator of women’s access to health services.26 Courtship violence and workplace violence. but in general. Assuming no discrimination in nutrition and health care on the basis of gender. rates of TB are generally high in South-East Asia. This poses a challenge to policy-makers. dowry abuse. causes impediments to effective treatment. Similar evidence exists for HIV/AIDS. women already account for 48% of infected adults.
104 in Bangladesh and Indonesia and 106 in Japan. the International Conference on Population and Development Cairo Programme of Action (1994). governance and civil society Human rights and health Health and human rights are closely linked. 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). These33 provide for: • • • The right to the highest attainable standard of physical and mental health. including the Convention on the Elimination of All Forms of Discrimination Against Women (1979). China’s high CSR is partly attributed to its one-child population policy. not the dispensation of a charitable or compassionate act. Violation or neglect of the human rights of women. Fulfilment of rights is an obligation of the duty-bearer. regardless of sex. The most populous countries in the Region also have high CSRs: 111 in China. adequate standard of living and adequate housing and a safe and healthy environment. The right to a safe and healthy workplace. denial of food and shelter. Stigmatization and discrimination thwart medical and public health efforts to heal people with disease or disability. Most countries of the Region are parties to conventions and agreements on health and human rights. men and children can have the most serious health consequences. A human rights-based approach legitimizes those claims. the Convention on the Rights of the Child (1989). • • Health in Asia and the Pacific . women and men to equitable distribution of food. the Beijing Platform of Action (1995). Such violations can take the form of torture and other forms of violence. How health delivery services are designed and positioned in society can either promote or violate people’s human rights.Chapter 2 24 The ratio of male to female children under age five (child sex ratio. safe drinking water and sanitation. Respect for the dignity and privacy of individuals can facilitate more sensitive and humane care.6 Human rights. Equal access to adequate health care and health-related services. It has been demonstrated that respect for human rights in the context of HIV/AIDS. and lack of access to health care facilities in times of distress. race or other status. the Social Summit Copenhagen Declaration (1995). and to adequate protection for pregnant women in work proven to be harmful to them. The right of all children. and points to the possible prevalence of sex-selective abortion and poorer care and nutrition of girls compared to boys.32 In an approach to health equity based on basic human needs. or CSR) is also an indicator of son preference. giving them political and legal weight. beneficiaries have no active claim to their needs being met. Freedom from discrimination and discriminatory social practices. including reproductive and sexual health. including prenatal gender selection and female infanticide. 2. Vulnerability to ill-health is reduced by promoting and protecting human rights. 107 in India (2001). mental illness and physical disability leads to markedly better prevention and treatment.
Acceptability: all health facilities. and effective intersectoral collaboration. a social justice-oriented policy climate agenda allowed rapid large-scale changes in the way health services interact with communities. as well as designed to respect confidentiality and improve the health status of those concerned. goods and services must be respectful of medical ethics and culturally appropriate. Quality: health facilities. goods and services. as well as access to health care and adverse health behaviours. Accessibility has four overlapping dimensions: non-discrimination. The National Public Health Council is headed by the Prime Minister. The government intends the National Public Health Council to be an effective tool for addressing the social determinants of health and increasing intersectoral collaboration. education. Interventions must tackle macro-environmental factors. In New Zealand. client-centred and gender-sensitive approaches. These documents emphasize the right to health. and preventing the social exclusion of vulnerable groups also addresses health equity and poverty. the Mongolia MDG Strategy 2000–2015. the private sector and international organizations. Box 2. NGOs. as well as programmes. must be available in sufficient quantity. WHO Regional Office for the Western Pacific.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 2001–2015. there are four major criteria by which to evaluate rights to health: (1) (2) Availability: functioning public health and health care facilities. and the Health Sector Strategic Master Plan 2006–2015. The complexity of the causes of inequalities in health means that multisectoral action is often needed. goods and services must be scientifically and medically appropriate and of good quality. well-being and equity. and call for pro-poor. economic accessibility or affordability. Social determinants of health 25 . health care and other services. • In concrete terms. sensitive to gender and life-cycle requirements. physical accessibility. China. Progress towards targets should be evaluated regularly to inform evidence-based policy refinements. including reproductive health and family planning to enable couples and individuals to decide freely and responsibly all matters of reproduction and sexuality. Social justice and inclusion policies are motivated by a general concern for human rights and dignity. Accessibility: health facilities. Beijing. The human right of the child to an environment appropriate for physical and mental development. Source: Report of the Consultation on Social Determinants of Health in the Western Pacific Region.• The right to education and access to information relating to health. goods and services have to be accessible to everyone without discrimination. Manila. 2006. and information accessibility. 22-24 March 2006. Specific interventions were supported by research evidence from the community level. It is responsible for ensuring intersectoral cooperation in implementing health policy and developing partnerships between government. within the jurisdiction of the state party. Improving access to employment. (3) (4) Reducing inequalities in health is an overarching aim of all public health policies.
and environment networks. employment and social factors. India’s National Right to Health Care Campaign (2004–2005). campaigns. lobbying and advocacy. Civil society organizations include health and development NGOs. implementation. Civil society and health The need to involve communities in planning. civil society involvement in health has also widened to include organizations whose main mandate lies outside the health sector. and service delivery. Data also pointed to poor housing as the cause of serious health problems in Maori neighbourhoods. investment. 16-18 October 2007. Significant advances achieved through interventions by civil society organizations include the India People’s Charter for Health (2000). 2007. 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). youth organizations not specifically set up to deal with health issues have contributed to adolescent reproductive health promotion. monitoring and evaluation of health programmes has been recognized as essential to comprehensive primary health care. Asian People’s Charter on HIV/AIDS (2003). health policy resource groups. Civil society action on social determinants can include participatory research. Life expectancy in years 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. A US$ 45 million housing improvement programme has benefited 5000 families in Auckland. Primary health organizations were introduced in the late 1990s to provide health care focused on the needs and participation of the community. Civil society organizations often work at the grassroots level and are able to articulate the needs and aspirations of communities. For example. Manila. WHO Regional Office for the Western Pacific. social movements. have played an important role in essential medicines lobbying. legal. issue-based resource centres. 26 Health in Asia and the Pacific . community health and development training NGOs.9: Primary health care and housing improvements in New Zealand Chapter 2 85 80 75 70 65 60 55 50 1950 1960 1970 1980 1990 Non-Maori (SNZ) Female 2000 Addressing health inequalities is a priority for health sector planning in New Zealand as well as a key focus in overall social policy. and groups such as trade unions. Maori (SNZ) Male Maori (SNZ) Female Maori (NZMCS) Male Maori (NZMCS) Female Non-Maori (SNZ) Male Source: High-level Meeting on Promoting Health Equity: Evidence.Box 2. Policy and Action. and the Mumbai Declaration for Health for All (2004). advocacy for the marginalized. which deal mainly with economic and trade issues. Phnom Penh. As attainment of health goals has become more influenced by political. especially the poor. trade. Cambodia.
social movements and political movements. Budgets are managed and allocated by the public–private coordinating committee. and works at three levels in civil society—vulnerable groups and people-based organizations. Sources: Report of the WHO Regional Consultation on Social Determinants of Health. and a holistic and integrated approach involving health and microcredit schemes. India: Launched in 2000. self-reliance. with a population of 1. and 500 villages in rural areas of 16 districts in Gujarat and Bihar states. 2001-2004. Tuberculosis and Malaria. the crisis is so severe that the Government alone cannot cope with the problem. and medical and pharmacy education. Health Action International: An international network of individuals and organizations based in the Netherlands involved in health and pharmaceutical issues. Although the Government is very active and the Prime Minister himself chairs the National AIDS Committee.go. health professionals (encouraged to participate in research activity) and political leadership. Thailand health profile.Box 2. The social crisis from the epidemic of HIV/AIDS started in the late 1980s. health financing.5 million. Available from: http:// www. the People’s Health Movement consists of a number of organizations. community-based organization. movements. 2005. traditional medicine. New Delhi. The Self Employed Women’s Association works both at grassroots levels and at policy levels. New Delhi. engaging with political parties before the parliamentary elections in 2004. health and trade interface. Bangkok. Their activities are based on knowledge management. One of the NGOs has been accepted as the Principal Recipient of the Global Fund. the Health Promotion Institute under the National Health Foundation and the Action for Smoking and Health Foundation. The Self Employed Women’s Association is a trade union of 700 000 women workers in the informal economy in Gujarat and seven other states in India. there were more than 100 000 cases of new infection per year. Tobacco control and HIV/AIDS in Thailand.PDF Social determinants of health 27 . India.10: Civil society actors in health in the Region People’s Health Movement and Self Employed Women’s Association. Activities include development of the People’s Charter for Health (2000). The civic network on HIV/AIDS has participated actively in the Country Coordinating Mechanism under the Global Fund to Fight AIDS.th/ops/health_48/CHAP12. Its health activities cover 30 wards in three urban areas with 1.2 million people. which receive strong support from the Government. campaigning for The National Right to Health Care by organizing public hearings in collaboration with the National Human Rights Commission of India. More than 100 civil society organizations on HIV/AIDS have been created. The network has partners in several countries in the Region. which led to framing of a National Health Action Plan. trade unions and women’s organizations. 15-16 September 2005. Ministry of Public Health. WHO Regional Office for South-East Asia.moph. The focus is on women-led. advocacy groups. During that period. Health Action International strives to create a just and equitable society and has organized campaigns on national drug policy. There are at least two very active civic organizations advocating for tobacco consumption control in Thailand.
This evidence was documented and presented in a series of national workshops and forums. Phnom Penh. their community-focused approach is now being replicated in another province. Management performance contracts proved successful in raising utilization. 16-18 October 2007. which helped to consolidate political commitment among high-level government offices. and Health Equity Funds were pilot tested in the last four years and found to be pro-poor and an efficient use of donor subsidies. and economic growth provided additional revenues. A joint research team from universities and provincial health authorities from Shandong Province and Ningxia Hui Autonomous Region has been working with local policy-makers to find better premium and reimbursement formulas that will benefit the most people at an affordable cost to local governments.1. Box 2. equitable and feasible. It introduced user fees as a part of health sector reform in the 1990s. As also mentioned in Box 2. a long-term primary health care (PHC) development project in Sayaboury province succeeded in making sustainable improvements in the health of the mostly ethnic minority. but studies showed that exemptions were not working well. Source: Report of the High-Level Meeting on Promoting Health Equity: Evidence. Policy and Action. health access for the poor is on the policy research agenda in China. Studies were conducted on utilization and household expenditure on health. 2007. and that when changes are made. isolated rural population. which means interventions must be efficient. Policy-makers are increasingly working closely with academic and other researchers to develop equity-relevant research. on equity of access to health care and on health outcomes.11: Improving equity with evidence-based policy Viet Nam frequently evaluates social determinants and has recently implemented the Health Care Fund for the Poor programme (Decision 139). with the worst effect on the poor. they consider the poor first and base changes on sound evidence (see Chapter 10). and researchers are developing effective ways to present evidence and use it to design cost-effective interventions. In the Lao People’s Democratic Republic. the national health insurance system was growing. that governments and health systems are responsive to needs of the poor and vulnerable. Policies must be based on evidence and have to be funded and implemented. these factors created a synergy that helped influence the highest level of Government. Manila. Together. Policies based on these research findings now allow gradual increases in premiums and benefits to be implemented. WHO Regional Office for the Western Pacific. The NGO providing assistance and the provincial health department documented the project activities and results carefully. the Chinese Government is relying heavily on The New Cooperative Medical Scheme to make health insurance available to all farmers. 28 Health in Asia and the Pacific .Good governance and health Chapter 2 Good governance of the health sector means. the national assembly and the finance sector to support the poor in paying for health care. The right to good health with dignity cannot be simply conferred by decree. the grassroots health-care system was being strengthened. The way that governments respond to good evidence of health inequities is a measure of health system governance. Policymakers in the Ministry of Health work closely with NGOs and researchers. At the same time. Cambodia has been systematically exploring health financing and equity for the last 10 years. that management and technical efficiency are constantly evaluated. For the large rural population. among other things.
if not greater than. as has primary school enrolment. especially female primary education. many others call for intersectoral action. economic development has brought some improvement in gender equality. As will be seen in following chapters. Some environmental and behavioural risk factors are related to poverty. Education is not a direct health sector issue. the proximal causes of disease. social. but many also concern the entire population of a geographic area. health systems in the Region can be made more responsive to poverty and other access issues. but many have a long way to go. While many can be addressed from within the health sector. At the same time.Conclusions Economic. It is encouraging to note rapid increases in the overall level of human development by some lowincome countries in the Region. Social determinants of health 29 . yet is among the most important determinants of health. but also brings environmental degradation and increased competition for all types of resources. The wide range of issues represented presents policy-makers with challenges as great. Predominant in the cluster of socioeconomic factors are those that determine equity of access to food and preventive and curative health care. Food security and nutrition have improved markedly. and environmental factors are powerful intermediate determinants of health in the Asia Pacific Region.
See: http://faostat. Rome.aspx Dietary fat consumption (grams/person/day) 1990–1992 130 19 71 22 55 100 102 41 53 80 94 46 60 23 97 46 79 42 32 104 129 41 116 44 43 46 36 98 28 2000-2002 135 26 72 31 86 99 122 52 60 86 101 35 76 28 84 64 83 48 37 111 117 48 132 42 44 51 40 88 43 .fao. protein and fat consumption in Asia Pacific countries with available data Dietary energy consumption (kcal/person/day) 1979–1981 3068 1981 2592 1713 2328 2500 2756 2083 2215 2709 2729 2295 2993 2074 2757 2162 2379 2325 1847 2911 3082 2219 2463 2223 2358 2276 2410 2564 2031 1990–1992 3175 2070 2798 1862 2707 2637 2863 2366 2698 2813 2653 2466 2998 2111 2830 2377 2066 2634 2346 2788 3204 2263 2569 2019 2230 2201 2564 2528 2177 2000–2002 3096 2192 2851 2058 2942 2941 2880 2423 2880 2781 2827 2144 3046 2291 2878 2548 2238 2874 2425 2777 3199 2435 2887 2242 2370 2399 2764 2582 2541 Dietary protein consumption (grams/person/day) 1979–1981 105 44 72 39 54 62 76 51 47 87 65 74 83 51 59 70 80 60 49 78 98 51 60 56 47 50 70 65 47 1990–1992 107 44 79 44 66 69 90 57 61 94 65 78 81 51 68 78 74 65 61 78 96 55 70 49 49 52 68 59 50 2000–2002 104 47 82 51 82 75 97 56 65 92 70 63 88 60 75 106 81 76 62 81 91 57 83 51 54 57 69 60 62 1979–1981 115 15 55 13 32 88 91 33 35 69 101 37 37 22 78 30 85 35 26 99 124 36 96 53 47 32 29 97 19 FAOSTAT. Food and Agriculture Organization of the Unite Nations.1 Country/area Year Australia Bangladesh Brunei Darussalam Cambodia China Fiji French Polynesia India Indonesia Japan Kiribati DPR Korea Republic of Korea Lao PDR Malaysia Maldives Mongolia Myanmar Nepal New Caledonia New Zealand Philippines Samoa Solomon Islands Sri Lanka Thailand Timor-Leste Vanuatu Viet Nam Source: 30 Health in Asia and the Pacific Dietary energy.org/site/502/default.Chapter 2 Annex Tables Table 2.
494 0. 0.409 .... 2002 0.321 0.731 0. 0.309 ..826 0.377 0.. ...480 0.223 ... 0.754 0.. .479 0.. New York.218 0.491 0.327 0.335 .715 0.218 0....519 0. 2001 0.364 .542 0.479 0.407 Human development reports.240 0.....759 0... 0..452 Australia Bangladesh Cambodia China Fiji India Indonesia Japan Republic of Korea Malaysia Mongolia New Zealand Philippines Singapore Sri Lanka Thailand ... . 0. ...772 0. .274 0.362 0.461 2005 0.707 0.347 . 0. 0....592 0.309 ..539 0. .304 ....364 ..384 .765 0.468 .654 0. 0. .526 0....490 0.272 0.806 0.... 0.520 0.750 0.756 0.503 .738 0..218 0.378 0..276 0...381 .531 0. 1999–2005 Gender empowerment measure 1999 2000 0.457 2004 0...594 0..648 0.458 2003 0.388 0.512 0. .523 0.505 ...336 0.358 0.323 0.527 0..503 . .534 0. 0.305 .769 0.Table 2.429 0. .. ...363 0. 0.509 0... . 0. .700 0..515 0..2 Country/area Trends in the gender empowerment measure (GEM) in selected Asia Pacific Region countries..502 0.370 0.. .... United Nations Development Programme Social determinants of health 31 . 0. 0. Data not available Source: 0..470 0.451 .. 0. ...505 0..
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