"(The) toxic combination of bad policies, economics, and politics is, in large measure responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible"

Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health

The Society and Health Network at the Public Health Foundation of India (PHFI) held a lecture by Professor Sir Michael Marmot, Chair of the World Health Organization's Commission on Social Determinants of Health. Professor Sir Marmot spoke on "Social Determinants of Health: Challenges and Opportunities for Low and Middle Income Countries", drawing from his vast research experience and a recently concluded study, titled- Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health.

Sir Marmot said clearly that the report title was only indicative of the vision and aspiration to achieve changes in conditions of daily life and policy, and was in no way a prediction that health gaps could be addressed in a generation's time. The report focused on social determinants of health in a three-year investigation by an eminent group of policy makers, academics, former heads of state and former ministers of health, comprising the World Health Organization's Commission on the Social Determinants of Health.

The report concluded that inequities in health are avoidable, but arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. This refers to inequities between and within countries in conditions of daily living, 'structural' conditions like social and economic policies as well as systems in place for surveillance and monitoring of inclusive health care.

Sir Marmot highlighted the importance of understanding social gradients responsible for poor health as well as improved health. Wealth alone does not determine the health of a nation's population. Some low-income countries, Costa Rica, China, Sri Lanka, Cuba and the state of Kerala in India have achieved good and equitable health in spite of relatively low levels of national wealth. Among the lessons drawn out by the report, from these countries is the importance of good social policy emphasizing education, particularly for girls and women.

Taking the specific health challenge of India still not on track to meet MDG 4- reducing under 5 mortality rates by 2015 (Countdown Group, 2008), the report and Sir Marmot suggested creating enabling policies to educate women for lower infant and child mortality rates. The report states that a comprehensive approach to the early years in life requires policy coherence, commitment, and leadership at the international and national level, such that even health ministries advocate for policy changes in education and gender equity. Sir Marmot also stressed the need for collective action in demanding and developing policies and programmes that close gaps in education and skills, and that support female economic participation.

The report exemplifies the Indian Government for providing work guarantees as a way to lift people above the national poverty line, since poverty and hunger are closely linked. It also recommends setting up robust social protection systems in all poor countries so that people in low-wage settings are able to afford and access health care. Towards this end, Sir Marmot remarked on the need to foster a global movement to create an enabling environment for recognition and action on social determinants of health, as a means of delivering social justice and saving lives.

Present in the audience were public health experts, academicians, researchers, policy makers, representatives of multilateral agencies, private foundations, media partners and civil society members.

PHFI was entrusted with the responsibility of organizing the first National Advocacy Workshop in New Delhi for Law Enforcers/ Government Officials, convened by MoHFW and supported by WHO.

PHFI coordinated connectivity with over 20 Government departments in 35 states and Union Territories, to ensure participation of key officials and stakeholders.

The workshop aimed at sensitization of national and state level law enforcement agencies (Police, Health authorities, Customs and Central Excise Officers, School officials etc.) on their preparedness and enforcement action plan to implement the COTPA-2003 and the FCTC.

An conference titled 'New Directions for Public Health Education in Low and Middle Income Countries', hosted by the Public Health Foundation of India with support from the Rockefeller Foundation, is one of the very first efforts that has ever been made in the direction of advancing innovative and strategic thinking for public health capacity-building in low and middle income countries (LMIC) in the 21st century.

The conference was designed to enable participants to review existing public health curricular content, design and implementation in order to devise recommendations that would be relevant for a new public health agenda. Major international organizations like the Bill and Melinda Gates Foundation and World Health Organization were among the agencies represented at the conference.

Health is increasingly being recognized as an important contributor to development. While clinical medicine has been seen as an important contributor to improving health, the field of Public health has long been neglected. However, in recent years setting up Public Health systems where diseases can be prevented and improved management is fostered, is slowly gaining priority.

The low and middle income countries have begun to recognize that health cannot be improved without improvement in the public health systems themselves. The key themes of the conference were improving connectivity between health systems and public health education, improving governance and resourcing of Public Health, addressing human resources for health and the role and scope of cross-cutting issues like social determinants, public health law, and heath communication in public health advancement.

Public health experts, academicians, researchers, policy makers, representatives of multilateral agencies, private foundations, and civil society members came together from around the world. Their objective at this conference was to design resource-sensitive and relevant public health institutions and networks that can advance the agenda of public health in LMIC. The use of information technology in advancing public health education and improving delivery of health services, was also discussed by experts connected from different regions of the world in a video conference.

The conference enabled an adequate mix of key public health professionals to advance the precept and practice of public health in multiple sectors by facilitating inter-disciplinary research that informs policy, empowers programmes and enriches the knowledge bank of public health through operational as well as etiologic research. It developed a framework for national and regional implementation of public health education programmes in a decentralized manner, while fostering global connectivity in an era where the scope, intensity and number of diseases are expanding. The event was envisioned to foster the redesign and reinforcement of health systems to create dependable delivery pathways for (health) promotive, (disease) preventive and curative services.

PHFI was requested by the MOHFW, GoI to organize a 6 days capacity building workshop for state tobacco control officers to orient them on tobacco control and to assist in their state action plan formation. This training workshop on Tobacco Control for State Programme Managers was held at the National Institute of Health and Family Welfare in New Delhi.

In order to equip State level Tobacco Control Program Managers with program implementation skills to effectively implement tobacco control goals in India, PHFI conducted a 'Workshop on Tobacco Control for State Program Managers' from June 30- July 5, 2008. This was designed as a customized, interactive training program and imparted skills and techniques to facilitate understanding of the tobacco epidemic in India, the NTCP and the Tobacco Control Act.

The workshop facilitated planning, implementation, monitoring and evaluation skills related to state level tobacco control programs. It also exposed state coordinators to advocacy, leadership and networking skills to build multi-stakeholder partnerships at state level. State and district levels action plans for tobacco control were designed on the basis of the training imparted and PHFI provided technical inputs to Central and state governments.

Dr. Subhadra Menon from the Health communication team at PHFI conducted a session on 'Advocacy: Effective strategy for positive change', highlighting the power of health promotion messages as part of state and district level enforcement action plans. The session was followed by a group exercise on media advocacy for tobacco control, as a simulation of networking, message design and promotion opportunities. The workshop aimed at sharing best practices in tobacco control and developing expertise to manage resources, including human resources, financial budgeting, training and advocacy to tackle the multi-dimensionality of tobacco issues in India.

A consultation on 'Public Health Law in India - Exploring partnerships and programmes for strengthened capacity' was held on 11 August, 2008 as an ancillary meeting to the to the International Conference on 'New Directions for Public Health Education in Low and Middle Income Countries' hosted by PHFI at Hyderabad, Andhra Pradesh, between 12-14 August, 2008, in collaboration with the Rockefeller Foundation.

It was a unique consultation since it was based on an effort to link public health with human rights and the law. It was designed as a discussion starter aimed at achieving a better understanding of current perspectives in public health law and potential areas for research and education. It is intended at mapping best practice and the use of legal tools for better public health outcomes so as to develop a framework for education, training and research in public health law through joint academic programmes and partnerships.

Several distinguished members of the academia, research and legal community participated in the consultation and discussed in depth the need for education, training and research in public health law. Some of the participants were:

• Dr. Madhava Menon, Member-Commission on Centre-State Relations
• Prof. Sripada Joga Rao, LegalExcel, Bangalore
• Dr. Amita Dhanda, Professor of Law, NALSAR, University of Law, Hyderabad
• Dr. Sri Ram Khanna, Managing Trustee, VOICE, New Delhi
• Prof. Wendy Parmet, Matthews Distinguished University, Professor of Law, Northeastern University School of Law, Boston
• Dr. Richard Cash, Senior Lecturer on International Health, Harvard School of Public Health
• Mrs. Aruna Sharma, Joint Secretary, National Human Rights Commission, New Delhi
• Dr. Amar Jesani, Coordinator, Centre for Studies in Ethics and Rights, Mumbai
• Dr. Ravi Narayan, Community Health Advisor, Community Health Cell, SOCHARA, Bangalore
• Dr. Prabhakaran, Executive Director, Centre for Chronic Disease Control (CCDC), New Delhi
• Dr. Geoffery Cannon, Director of Science and Policy, World Health Policy Forum, Sao Paulo, Brazil
• Dr. Mala Ramanathan, Additional Professor, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram
• Shruti Pandey, Senior Consultant on Legal Framework National Health Systems Resource Centre (NHSRC), New Delhi
• Prof. Richard Daynard, Professor of Law, Northeastern University School of Law, Boston
• Anand Grover, Practicing lawyer, Director Lawyers Collective HIV/AIDS unit, Mumbai and UN Special Rapporteur on the Right to Health
• Shri R. Rajamani, Ex-Secretary, Ministry of Environment and Forests, Government of India, Hyderabad
• Prof. Surya Prakash; Professor of Law, National Law Institute University, Bhopal
• Dr. David Sanders, Director of School of Public Health, University of Western Cape, Cape Town

The consultation was divided into three panel discussions focusing on 'public health law education', 'mapping best practices and identifying new priorities', and 'strengthening of public health law in the 21st century'. There were several recommendations which emerged, some of which were the need to develop a platform for partnerships and collaboration between schools of public health and law schools. It was recommended that joint teaching programmes are introduced and inter-disciplinary curricula be developed incorporating elements of health and policy into legal education. A joint action using law as a tool for social change was also recommended which could bring about continued interaction between the NGOs and the law community through joint advocacy and training. PHFI is now in the process of putting together a framework for action, based on the discussions which took place in the consultation.

Foundation Day of the Public Health Foundation of India was celebrated on March 28, 2008. The first Foundation Day Lecture, an oration to be delivered by a distinguished leader in a public health area of great national and global significance was held in the presence of an august gathering in New Delhi. The PHFI Award, another novel endeavour was instituted to honour Indian contributions in the field of public health.

The inaugural Foundation Day Lecture and Award function was held at the India Habitat Centre and attended by more than 400 people from government, academia, multilateral organizations, NGOs, donors, the media, and the corporate sector and by university and school students. Shri Naresh Dayal, Secretary Health, Ministry of Health & Family Welfare, Government of India, was the Guest of Honour at the function. The event was extensively covered in both print and electronic media.

In keeping with global recognition of the challenge from rapidly occurring climate change and its impact on health, the PHFI Foundation Day lecture focused on "Environment, Climate and Health: An Expanded Public Health Research and Policy Agenda for the 21st Century" by Professor Anthony J McMichael, NHMRC Australia Fellow at the National Centre for Epidemiology and Population Health, The Australian National University, Canberra.

This year's PHFI Award was presented to Professor Kalpana Balakrishnan, Professor of Biophysics and Head, Department of Environmental Health Engineering, Sri Ramachandra University, Chennai for her abiding commitment to environmental health environmental epidemiology, industrial hygiene and safety, and occupational health. Dr. Balakrishnan obtained her undergraduate degree from AIIMS, New Delhi, and subsequently her doctoral and post doctoral training at the Johns Hopkins University in Baltimore, Maryland, USA in Biophysics and Environmental Health Engineering respectively. She is also Director of the WHO Collaborating Centre for Occupational Health at Sri Ramachandra University, Chennai.

The Foundation Day celebrations also included an exhibition on the "Impact of climate Change on Health" by our partner organization, Hriday Shan. The exhibition featured a series of posters and children's electronic games prepared by Hriday Shan for spreading awareness about how climate change is affecting human health.

PHFI thanks the Nand & Jeet Khemka Foundation (NJKF) for co-organizing this event as part of the NJKF's Climate Change Series.

Useful links:
Detailed Programme of the Foundation Day Lecture 2008
Prof. Anthony J McMichael’s Profile
A brief abstract of the lecture