ECOHEALTHSustaining Ecosystems. Supporting Health

4th Biennial Conference of International Association for Ecology and Health

15–18 October 2012, Kunming, P.R. China

Health and Sustainability Challenges of the 21st Century

Jacobo Finkelman

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. WHO, 1946

health

EpidemiologicalDemographic

changes

EpidemiologicalDemographic

changes

EnvironmentalSocial

determinants

EnvironmentalSocial

determinants

politicalpolitical

developmentdevelopment

culturalcultural

ethicalethical

Technological innovations

Technological innovations

BiomedicalHealth careBiomedicalHealth care

health: increasingly complex and dynamic

Social

Economic Environmental

A new paradigm integrating health in sustainable development

Health is a precondition for and an outcome, as well as an indicator of all three dimensions of sustainable development. (Future We Want, 2012)

Health

ECO1992ECO1992

RIO+202012

RIO+202012

MDG2000MDG2000

Human Rights, 1993Population ,1994Women,1995Social Develop 1995COP 1 CC, 1995Habitat II , 1996Food,1996

Human Rights, 1993Population ,1994Women,1995Social Develop 1995COP 1 CC, 1995Habitat II , 1996Food,1996

Monterrey, 2002Millennium II, 2005Millennium III, 2010Johannesburg, 2010

Monterrey, 2002Millennium II, 2005Millennium III, 2010Johannesburg, 2010

Stockholm,1972Alma Ata, 1978Ottawa ,1986Brundtland Report ,1987

Stockholm,1972Alma Ata, 1978Ottawa ,1986Brundtland Report ,1987

20152015

4 Decades of UN Summits and High Level Meetings

UN CONFERENCE ON ENVIRONMENT AND DEVELOPMENT. RIO, 1992INTERNATIONAL TREATIES

•UN Framework Convention on Climate Change (UNFCCC)•UN Convention on Biological Diversity (UNCBD)•UN Convention to Combat Desertification (UNCCD)

INTERNATIONAL TREATIES•UN Framework Convention on Climate Change (UNFCCC)•UN Convention on Biological Diversity (UNCBD)•UN Convention to Combat Desertification (UNCCD)

RIO DECLARATION ON ENVIRONMENT AND DEVELOPMENTPRINCIPLE 1

“Human beings are at the centre of concerns for sustainable development. They are entitled to a healthy and productive life in harmony with nature”

RIO DECLARATION ON ENVIRONMENT AND DEVELOPMENTPRINCIPLE 1

“Human beings are at the centre of concerns for sustainable development. They are entitled to a healthy and productive life in harmony with nature”

ROAD MAP40 CHAPTERSCH. 6 HEALTH

ROAD MAP40 CHAPTERSCH. 6 HEALTH

No Targets, indicators and

operational definitions

No Targets, indicators and

operational definitions

AGENDA 21AGENDA 21

UN CONFERENCE ON SUSTAINABLE DEVELOPMENT, RIO 2012Rio + 20

CENTRAL THEMES(a) economy in the context of sustainable development and poverty eradication(b) Institutional framework for sustainable development

THE FUTURE WE WANT (six sections, 283 paragraphs)

CENTRAL THEMES(a) economy in the context of sustainable development and poverty eradication(b) Institutional framework for sustainable development

THE FUTURE WE WANT (six sections, 283 paragraphs)

MAIN OUTCOMES•Renewed commitment to sustainable development•Eradicating poverty is the greatest global challenge •Promoting sustainable production and consumption. Green economy•Reversing global environmental changes•Commitment with MDG and SDG•Democracy and governance

MAIN OUTCOMES•Renewed commitment to sustainable development•Eradicating poverty is the greatest global challenge •Promoting sustainable production and consumption. Green economy•Reversing global environmental changes•Commitment with MDG and SDG•Democracy and governance

MAIN SHORTCOMINGS•Green economy severely questioned by social movements•No major break troughs on institutional governance•Lack of goals, targets and indicators•Lack of financial commitments

MAIN SHORTCOMINGS•Green economy severely questioned by social movements•No major break troughs on institutional governance•Lack of goals, targets and indicators•Lack of financial commitments

•Intensive participation of civil society. ~ 3000 non – official paralel events•Health better positioned as initially expected

•Intensive participation of civil society. ~ 3000 non – official paralel events•Health better positioned as initially expected

Major heath issues addressed at ECO 92 and Rio + 20

ECO 92

Ch 6. Protecting and Promoting Human Health

a) Meeting primary health care needs, particularly in rural areas;

b) Control of communicable diseases;

c) Protecting vulnerable groups;d) Meeting the urban health

challenge;e) Reducing health risks from

environmental pollution and hazards

RIO + 20Paragraphs 138-146

a) Universal and equitable health coverage

b) HIV and AIDS, malaria, tuberculosis, influenza, NTDs and polio

c) NCD: cancers, CV, CRD and diabetesd) Health effects of air, water and

chemical pollutione) TRIPS. Public health rightsf) Strengthen health systems. Financing,

retention of work forceg) Population trends and projections in

development strategies and policiesh) Sexual and reproductive healthi) Reduce maternal and child mortality

Millennium Declaration 2000PRINCIPLES

a) Development and poverty eradication b) Peace and security c) environmental conservation d) democracy and human rights

GOAL 1: eradícate extreme poverty & hungerGOAL 2: achieve universal primary educationGOAL 3: promote gender equality and empower womenGOAL 4: reduce child mortalityGOAL 5: improve maternal healthGOAL 6: combat HIV/AIDS, malaria and other diseasesGOAL 7: ensure environmental sustainabilityGOAL 8: develop a global partnership for development

MDG8 GOALS, 18 TARGETS AND 48 INDICATORS

MDG8 GOALS, 18 TARGETS AND 48 INDICATORS

Three years to the deadline. UN sources

People living in extreme poverty (less than $1.25/day) fell from 47 to 24% (1990 - 2008) a reduction from over 2 billion to 1.4 billion individuals. Yet, 15.5% of the world population is undernourished. (2006- 2008)

Access to safe drinking water raised from 76 to 89% (1990 – 2010) Over two billion people gained access to improved drinking water. Great disparity between urban and rural.

Half of the population in developing regions—2.5 billion—still lacks access to improved sanitation facilities. By 2015, the world will have reached only 67% coverage, well short of the 75% needed to achieve the MDG target.

Urban residents in slums declined from 39 to 33% by 2012. Yet, in absolute numbers the slum population grew from 650 to 863 million (1990 – 2010)

Enrolment rates of children of primary school age increased and drop-out school rates decli8ned. Parity in primary education between girls and boys grew from 91 to 97 (1990 - 2010)

Three years to the deadlineUN sources

Child survival progress is gaining momentum. The number of under-five deaths worldwide fell from more than 12.0 to 7.6 million (1990 – 2010)

Despite some improvements decreases in maternal mortality are far from the 2015 target. Since 2000, reductions in adolescent childbearing and expansion of contraceptive use have continued at a slower pace

Access to treatment for people living with HIV increased. 6.5 million were under antiretroviral therapy (2010). The target of universal access, has not been reached.

The world is on track to achieve the target of halting and reversing the spread of tuberculosis

Global malaria deaths have declinedThe estimated incidence has decreased globally by 17% since 2000 and, mortality rates have decreased by 25%.

Health MDGs gained traction for a number of reasons. • Encapsulated some of the most serious challenges affecting child and maternal mortality, infectious diseases including HIV/AIDS, malaria and tuberculosis.

• Financial and technical support (Global Fund, GAVI, RBM)

• Built upon decades of development efforts expressed through global and regional conferences

• Simple format of concise goals, targets and indicators with defined time lines intuitively attractive and readily understandable.

Lessons learnt from the health-related MDGS

• A top down, technocratic approach to the selection of goals, targets and indicators. From global to national: a difficult translation

• Limited organized framework for health and development

• Reductionist approach between the goals, targets and indicators.

• Relevant issues were left out

• Lack of clarity in definitions and limited attention to its feasibility

• Variability in the formulation of the targets.

•Lack of attention to disaggregated monitoring process. Uneven distribution of benefits

International financial assistance2000 - 2010

SUSTAINABLE DEVELOPMENT

“development that meets their present needs without compromising the ability of future generations to meet their own” Our Common Future, 1987

Shared values:Solidarity, equity, dignity and respect for nature

economic

Sustainable development

social

environmental

Integrated framework post 2015

Universal access to quality care

Spending on health: A global overviewWHO, 2012

Spending on health: A global overviewWHO, 2012

Universal Health Coverage“Is a system in which everyone can get the health services they need

without incurring in financial hardship” WHO, 2005

Health care Public health

Market

HEALTH CARE “The prevention, treatment, and management of illness and the preservation of mental and physical well-being through the services offered by the medical and allied health professions”. Medical Dictionary, 2007 • Disease oriented( past individual exposures and biological/genetic disorders)• Traditional preventive programs (proximal)• Services are segmented and fragmented •Hospital driven. Week PHC• Offer and demand unbalances•Ill prepared to address demographic, epidemiological, technological, economic, cultural, information and political changes

PUBLIC HEALTH “is the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts” Charles Winslow, 1920

• future oriented. Public good

• collective or social actions (proximal and structural)

• strong ethical and human rights foundations

• shared responsibility (governments, communities, families, and individuals )

• Ill prepared to address demographic, epidemiological, technological,

economic, cultural, information and political changes

Social determinants of health The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries. WHO Commission on Social Determinants of Health. 2008

Key commonalities between PHC and the SDH paradigms•Central focus on health equity.•Relevant in all countries and contexts, regardless of income level.•Health is more than the absence of disease.•Key role for health sector.•Promotion of multisectoral action and consideration of health in all policies.•Emphasize role of empowered communities

market

Debate is focused on:costs rather then health outcomes private/public mix of providers profit – human rights social inclusion – exclusion global – local steering process (citizens, state market)

Universal Health increasingly driven by the expectation that health can be created, managed

and produced

World Health SummitBerlin, Germany Oct 21 -24 , 2012

World Health SummitBerlin, Germany Oct 21 -24 , 2012

8th Global Conference on Health Promotion

Helsinki, Finland 10-14 June 2013

8th Global Conference on Health Promotion

Helsinki, Finland 10-14 June 2013

•To engender improvement of health care worldwide by strengthening the links in place between research, academic medicine and decision makers across all healthcare sectors, including government and industry.

•To influence, guide and support positive action by policy and decision makers through the provision of credible and scientifically-based evidence.

•To maintain an international, multi-sectoral health forum, sustaining dialogue, creating networks and fostering collaboration as a catalyst for innovation and measurable health care improvement.

•To promote thought leadership through academic input into the scientific and global health agenda.

World Health SummitBerlin, Germany Oct 21 -24

Goals

8th Global Conference on Health PromotionHelsinki, Finland 10-14 June 2013

Conference aims

• exchange of experiences to provide guidance on effective mechanisms for promoting intersectoral action

•address barriers and build capacity for implementing HiAP

•implement recommendations of the Commission on Social Determinants of Health through HiAP

•review economic, developmental and social case for investing in HiAP

•health promotion in the renewal and reform of PHC

Governance

• The call for governance innovation is a major consideration in all international documents

• Reduce fragmentation/overlapping • Increase coherence, transparency and efficacy• Not universal consensus on its meaning.

Involves: actors, organizational structures and practices, in a given context (subnational, national, regional, global)

Multi and Intersectoriality adds complexityScience and perceptions are both relevant

Post 2015 SDG ChallengesIssues:

• New narrative, new instruments, old policies?• Clear set of values (human rights, equity, sustainability)• Multidimensionality of human well – being• Interrelated global, national and local problems• Stronger emphasis on poverty elimination. Empowerment of most vulnerable• Unfinished agenda (vertical – comprehensive)Process: • Highly competitive. • Global goals, but countries should adapt targets to national and subnational contexts through democratic consultations • Clarity in definitions and measurement • Realistic time horizons

post-2015 UN development agenda road map

National consultations May 1, 2012 - Jan , 2013.

Thematic events . Nine thematic events on key post-2015

High-level Panel on Post-2015 Jul 1, 2012. Report Feb 1, 2013..

Sustainable Development Solutions Network. Aug, 2012

General Assembly High-level Meeting on MDGs Sep 23, 2013

National consultations, beyond 2015

AFRICA

Angola, Burkina Faso, CAR, DRC, Ethiopia, Ghana, Kenya, Mali, Malawi, Mauritius, Mozambique, Niger, Nigeria, Senegal, South Africa, Tanzania, Togo, Uganda, Zambia

ASIA AND PACIFICBangladesh, Bhutan, Cambodia, China, India, Indonesia, Iran, Lao PDR, Pakistan, Philippines, PNG, Samoa, Solomon Islands, Timor-Leste, Vietnam

LACBolivia, Brazil, Colombia, Costa Rica, El Salvador, Guatemala, Honduras, Peru, Santa Lucia

ARAB STATES Algeria, Djibouti, Egypt, Jordan, Morocco, Sudan

EASTERN EUROPE AND CISAlbania, Armenia, Kazakhstan, Moldova, Tajikistan, Turkey

thematic events beyond 2015

Health in the Post-2015 Development AgendaGlobal conversation . Call for Papers

1. What are the lessons learnt from the health related MDGs?2. What is the priority health agenda for the 15 years after 2015?3. How does health fit in the post 2015 development agenda?4. What are the best indicators and targets for health?5. How can country ownership, commitment, capacity and accountability for

the goals, targets and indicators be enhanced? 6. How can we ensure effective working relations between countries and global

partners in terms of alignment and harmonization with a focus on development results?

Manuscripts (maximum 3000 words, excluding annexes) should be submitted by email to post2015health@who.int Oct 5 – Dec 15, 2012. English or French.

Face to face consultations • II Global Health Systems Research. Beijing, China. Nov 1-2,2012• WHO consultation, Geneva, mid-December

“The challenge is how to frame an overarching health goal and target in a way that drives change that is relevant for all countries; that acknowledges health as a global concern that appeals to politicians to the public; and is actually mesurable. No easy task”

UN SYSTEM TASK TEAM ON THE POST 2015 UN DEVELOPMENT AGENDA http://www.worldwewant2015.org/health