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8th Global Conference on Health PromotionTackling health inequality through allPoliciesCecilia Vaca Jones,June 2013.


Sumak Kawsay-Good LivingEssential framework of the Ecuadorian Government action


Objetive 1:To foster social and territorialequality, cohesion and integrationwith diversityObjective 2:To improve the citizens ‘capabilities and potentialitiesObjective 3:To improve the quality of life ofthe populationObjective 4:To guarantee the rights of natureand promote healthy andsustainable environmentObjective 5:To guarantee sovereignty andpeace; to promote Ecuador’sstrategic insertion in the worldand Latin American integrationObjective 6:To guarantee stable, fair anddignified work in its diverse formsObjetive 7:To build and strengthen public andintercultural spaces for socialinteractionObjetive 8:To affirm and strengthen nationalidentity, diverse identities,plurinationality and interculturalityObjetive 9:To guarantee rights and justiceObjective 10:To guarantee access to public andpolitical participationObjetive 11:To establish a sustainable socioeconomicsystem based onsolidarityObjetive 12:To build a democratic State forGood Living


Human securityand transportHealthSocial securityScience andtechnologyLeisureNATIONALSYSTEM OFINCLUSIONAND SOCIALEQUITYEducationRiskmanagementCommunicationand informationPhysical cultureand sportCultureHabitat andhousing


SocialdevelopmentsectorArticulates andcoordinates thepolicies of socialdevelopment sector


Ensurehealthy andnutritiousfoodImprovequality ineducationRespect andrecognize theancestralmedicalpracticesPromotesports andphysicalactivityPromotehealthylivingpracticesStrengthenprevention,control andsurveillance ofdiseasesPromote integralattention throughlifecycleEnsure an earlychildhoodsystemGuaranteehousing andhealthy anddignified habitatStrengthenIntegralsocialprotectionReduce social andenvironmentalvulnerabilityOvercomeinequalitiesPoliciestogenerateequityPromote anuniversal socialsecurity system


RESULTS


SOCIAL INVESTMENTWe focus on the social development of the country7 000,00BUDGET EVOLUTION6 000,005 609,005 835,005 000,004 000,003 762,003 910,004 467,003 000,002 608,002 000,001 934,001 000,00-2006 2007 2008 2009 2010 2011 2012Source: Ministry of Finance –ESIGEF-


SOCIAL INVESTMENT PER PERSONWe invest in the human being to ensure equality and fairnessBetween 2006 and 2011 social spending per person on health, education,culture, security, environment, increased by USD 299.Social investment per personFuente: Ministry of Social Development (MCDS),Integrated System of Social Indicators of Ecuador (SIISE)


Our main objective is to eradicate povertyINCOME POVERTY REDUCTION4037,6%353028,6%27,3%2520151016,9%11,6% 11,2%PovertyExtreme poverty502006 2011 2012Source: National Institute of Statistics and Census. ENEMDU.


INCREASING EQUALITYWe continue narrowing the gap between rich and poor%Source: National Secretariat of Planning and Development –SENPLADES-


EDUCATION MANAGEMENTMore than 500.000 children and teenagers were included in theeducational system96,0%95,0%94,0%93,0%Elementary schooleducationNet attendance rate95,4% 95,6%70,0%60,0%50,0%40,0%Highschool educationNet attendance rate47,9%62,1% 63,9%92,0%91,2%30,0%91,0%90,0%89,0%20,0%10,0%88,0%2006 2011 20120,0%2006 2011 2012Source: National Institute of Statistics and Census. ENEMDU


WATER SAFETYUniversal access to safe drinking water85%75%65%80,7% 76,8% 72,7% 76,2%70,0% 73,2% 74,8% 75,2%73,7%68,2% 71,1% 70,1%70,5%62,9% 62,2%64,3%76,4%72,1%73,3%61,2%85,9%78,5%78,8%75,6%73,8%72,6% 73,8%74,4%84,4%79,5%80,2%78,5%73,8% 74,5%68,5%64,7%55%45%35%39,5%44,5%37,2%43,6%46,7%42,9%40,4%34,6%42,3%40,1%25%29,6%2003 2005 2006 2007 2008 2009 2010 2011 2012Nacional Afroecuatoriano Blanco Indígena Mestizo MontubioSource: National Institute of Statistics and Census. ENEMDU


SEWERAGE SYSTEMUniversal access to basic sanitation services80%79,4%70,6%72,1%70%71,6%63,4%60,2% 66,6%70,0% 65,5%63,4%63,2%64,4%60%60,8%58,1% 57,6%59,5% 58,8%57,8%58,3%55,2% 54,8%60,8% 57,6% 54,9%53,0% 52,6%55,2%51,9%50%51,6%49,5%52,9%46,9%41,7%40%39,3%37,1%36,3%30%27,4% 28,1% 27,2%24,4% 24,7%24,4% 24,5%20% 20,0%19,9%17,9%16,3%10%10,9%2003 2005 2006 2007 2008 2009 2010 2011 2012Nacional Afroecuatoriano Blanco Indígena Mestizo MontubioSource: National Institute of Statistics and Census. ENEMDU


DIGNIFIED HOUSING AND PLANNED URBANDEVELOPMENTWe foster good housing atmospheres to create social cohesionQualitative HousingDeficitQuantitative HousingDeficit35,6%36,3%21,2%19,3%34,4%33,2%16,5%13,7%2009 2010 2011 20122009 2010 2011 2012Source: National Institute of Statistics and Census .ENEMDU


PorcentajeSOCIAL PROTECTION AND SOCIAL SECURITYWe have significantly increased the social security coverage70,060,050,040,030,020,010,00,02007 2008 2009 2010 2011 2012PEA EAP covered by social security insurance 25,7 27,1 29,55 33,1 37,95 41,21Ocupados Full-time employees plenos cubiertos covered by por elsocial security seguro social41,30 43,70 50,60 55,00 61,70 63,70Source: National Institute of Statistics and Census . ENEMDU


SOCIAL PROTECTION AND SOCIAL SECURITYWe are moving towards an universal social security systemPensions for seniorsPensions for Peoplewith Disabilities600 000588 152120 000104 888500 000100 000400 00080 000300 000200 000198 05660 00040 000100 00020 0005 03902006' 2012'02006' 2012'Source: Viceministry of Insurance and Social Movility–MIES-


HEALTH CARE AVAILABLE TO ALLWe are constructing a friendly, free and accessible health caresystem45,0040,0035,0030,0025,0020,0015,0010,005,0016,2220,33Ministry of Public HealthAppointments per year(millions)25,5130,9334,40 34,6140,000,002006 2007 2008 2009 2010 2011 2012Source: Ministry of Public Health


We protect the most vulnerable peopleNumber of children withneonatal screening16000080 000 00070 000 00060 000 00050 000 00040 000 000NEONATAL SCREENING ANDCATASTROPHIC ILLNESSBudget for Rare and CatastrophicDiseases(millon USD)70 477 59080 000 000030 000 00020 000 0002006 201210 000 00004 129 0002006' 2011' 2012'Source: Ministry of Public Health


RIGHTS OF NATUREWe promote a healthy, friendly and dignified environmentfor allNature or Pacha Mama, the place where lifereproduces itself and accomplishes itself, hasthe right to be fully respected regarding itsexistence, maintenance and regeneration ofvital cycles, structures, functions andevolutionary processes. (Art.71 Constitution ofthe Republic of Ecuador).


Social Achievements


We are building the“Sumak Kawsay”society


Health &Development AgendaTriono Soendoro, MD., Ph.DMember of National Committee, Post-MDG2015 office of the President &Chair, Post-MDG 2015 Agenda, MoH


A NEW GLOBAL PARTNERSHIPEradicate Poverty & TransformEconomies through SustainableDevelopmenthttp://www.un.org/sg/management/pdf/HLP_P2015_Report.pdf24


Session Outline1. The consultation process (NY,London, Monrovia, Jakarta, Bali –from July 2012 – (final report)2. Botswana: Feb 20133. Bangkok (SEARO): March 20134. Final Report: April-June 20135. The Way Forward


Ban Ki Moon & Co-Chairs• I look forward to the Panel’srecommendations on a global post-2015 agenda with “sharedresponsibilities for all countries andwith the fight against poverty andsustainable development at its core.”(25/7/2012)


The Journey: Dev. Agendahow the various sectors (evenwithin health) collaborate and“compete” with each other&how health has eventually beenincluded


Health & Others: Competes..• 11 thematic group including health, led byBotswana and Sweden, supports from WHOand UNICEF• Address 3 issues: unfinished agenda ofMDGs; emerging threats - health transition nglobalization; health in the post 2015 developagenda• Final report: submitted to the UN-SG in May30 and discuss in the UN-GA in Sept 2013


Serial Consultation: Wants..• Overarching, aspirational healthgoals;• Stick with focused, targeted MDG-likegoals; and• Supports a tiered approach with ahierarchy of health goals and subgoals.


Intensive DialogueFrom MDGs 2000 to Post MDGs2015 development agenda:• What to keep,• What to amend, and• What to add


Botswana: 4-6 March 2013• Participants – 50 high level persons includingministers, members of the HLP, chiefs of IGOs,INGOs, private sectors, and high level experts.• The culmination of 6 months extensiveconsultation on how health should be addressedin the post 2015 development agenda• Web-based with 150,000 visitors, 13 face to facewith 1,500 pants and more than 100 paperssubmitted to www.worldwewant2015.org/healthwith 3 proposed targets - HLE, UHC, MDG++


Post-2015: The Goals1. Long healthy lives: is an end goal, influencedby health but also by many other aspects ofdevelopment2. Universal Health Coverage: contribution ofhealth to the end goal, supported in manypapers3. Continued Health MDGs, with equity element4. Several specific goals proposed, e.g. Universalaccess to sexual and reproductive rights orimprovements in mental health.Equity and human rights as central elements


Bangkok: Mid-March13Post-MDG 2015 Agenda:Shape, Themes, Contents?


VISION: Bangkok (mid-March)• Vision: “Ending Poverty by promotingequitable development, sustainable growthwith equity through strengthenpartnership”….• Vision: Human Well-being for all by 2030?• Vision: The fulfillment of the constitutiveelements of human Well-being for all by2030?• Remember: Health for all by 2000?34


Our Challenges: Framework?• Human Well-being: human as the central forthe development (overaching).• Thus, how to attain the constitutiveelements of HUMAN: Vision.• Shift: human as resources (OBJ) to humanas human-being (SBJT)• Poverty, promote equitable development,sustainable, environment, education, healthetc are the instruments (object), not the(subject) for the development35


The Constitutive Element: VisionHuman36


The Linkage: As Systems• Requires careful consideration, bothhealth vis a vis other developmentareas, and of the various elementswithin the health agenda as aSYSTEMS.• It is clear: the new framework mustaddress the limitations of the MDGs37


SystemsA system is something that:• maintains its existence and• functions as a whole• through the interaction of itsparts.


Thus, Systems Thinking• looks at the whole andthe parts and• the interactions amongthe parts• studying the whole inorder to understand theparts


Non-Systems Thinking• Reductionism, which is theusual scientific (technical,managerial) approach,looks at the parts in orderto try to understand thewhole.• >400 years (descartes)• Now, we have to shift ourway of thinking,fragmentation?


Analytical Thinking“We have been taught how tosolve problems, but hardly howto define them.”Jamshid Gharajedaghi


Pro-Cons: Systems Thinking• Rationalize target settingand help develop a limitedset of numeric targets thatare adaptable at countrylevel and relevant globally.• Hierarchy of more sectorandprogram specific goals,targets and indicators canreflect existing agreements(including the currentMDGs) and incorporateelements of the new healthagenda• Difficult to adapt,fragmentation to becomeintegrated – systemsthinking.• Dichotomous thinking:preventive promotive vscurative.• Changes our perception,concepts: academic,practitioners, etc• Health systemsimprovements: hard tounderstand


The Content (Bali Consult..)• The content of post-2015 developmentagenda encompasses a set of importantissues.• These issues are overarching and relatedin one or other ways to sustainabledevelopment as the “interlinking” theme.HLPEP 4th meeting; Bali 25-27 March 201343


Content (GOALS): 15…• Poverty and inequality• Food security• Education• Health• Governance andtransparency• Employment and livelihoodsecurity• Environmental sustainability• Water and energy• Peace, security, and socialprotection• Cities and urbanization• Access to technology• Gender and youth• Ocean and seas• Disaster risk reduction• Sustainable consumptionand production patterns• …etc


Bangkok Recommendations• Maximizing health at all stages of life asoverarching health goal with two specifichealth sector goals, i.e., acceleratingprogress of MDGs 4, 5 and 6, and reducingburden from NCDs• UHC is the health sector key contributionand include ‘Universal access to qualitycomprehensive essential health serviceswithout financial barriers’


Post 2015 Development Agenda: MODELContributions of the health & other sectorsSustainableWellbeing for All(Wealth, healthy lives,education, nutrition,environment, etc.)UHCAccess to qualitycomprehensive essentialprimary care services(including all MDG++and NCDs), financial riskprotectionHealth sectorcontributionOther sectorcontributions


The Frame of Goals (April)• MDGs 1-6– Halve poverty– Provide basic needs• MDGs 7-8– Enviromental stability– Aid(Keep, Adapt, Add)• Raise level of ambition– End poverty– Leave no one behind• Use Resource Wisely– Manage as best– Beyond Aid(partnership)• Transformation– All inclusive– Fair, equal, accountable


Goals & Targets: Health• Promote qualityhealth care• Maximize healthylives and wellbeing• Maximize healthat all stages oflife• Reduce child death


Session: Final Report1. Botswana – Feb 20132. Bangkok (SEARO) – March 20133. Post MDG-2015 developmentconsultation process – (Jul 12 –May 2013 – semi final report)4. Final report: June 2013


Our Vision & Responsibility“To end extreme poverty in all itsforms in the context of sustainabledevelopment and to have in placethe building blocks of sustainedprosperity for all”


Partnerships (Bali)• Multi-stakeholder partnerships, nolonger fragmented• Enables innovation, convinceadvocacy for good policies (HiAP?),secure funding• Implementation and scaling up toreach larger population


Five Principles: Goals1. Leave No One Behind.2. Put Sustainable Development at the Core3. Transform Economies for Jobs andInclusive Growth.4. Build Peace and Effective, Open andAccountable Institutions for All.5. Forge a New Global Partnership.


Global Goals & National Plans• An approach for unifying global goals.• Enable every nation to realize its ownhopes and plans• Choose an appropriate level ofambition for each target• Input on what is realistic andachievable target at all level


Goal 4: Ensure Healthy Lives• Focus on health outcomes; requiresuniversal acces to basic health caremeans:1. Reaching more people for essentialservices2. Broadening range of integratedservices3. Affordable4. Avoid discrimination


Goal 4: Cont’nd• Ensure equity: interconnected(interaction social, econ & envir)• Investing more in health: promotionand prevention (vaccination)• Strengthening health system: healthworkers, nutritious food, safe waterand sanitation, etc


Goals, Targets, and IndicatorsTerm How it is Used in the Report Example from MDGsGoals Expresses an ambitious, butspecific, commitment. Always startswith a verb/action.(ENSURE HEALTHY LIVES)Reduce child mortalityTargets 1,2,3Quantified sub-components thatwill contribute in a major way toachievement of goal. Should be anoutcome variable.Reduce by two-thirds,between 1990 and 2015(


Target:1,2, and 31. Candidates for global minimumstandards, including ‘zero’goals;2. Indicators to be disaggregated;3. Targets require further technicalwork to find appropriate indicators


Health: Target 1,21. End preventable infant and under-5 deaths.2. Increase by x% the proportion of children,adolescents, at-risk adults and older peoplethat are fully vaccinated.3. Decrease the maternal mortality ratio to nomore than x per 100,000.4. Ensure universal sexual and reproductivehealth and rights.5. Reduce the burden of disease from HIV/AIDS,tuberculosis, malaria, NTD and priority NCD 3


The Way Forward• Set of Goals or Goals: to be debated,discussed, and improved (until…2015?)• Select targets at global level, national levelor even local level• Setting global minimum standard forselected indicators (“data revolution”)• Setting disaggregate for relevantindicators• Develop & formulate “agenda for HiAP”


Public Health Agency of CanadaAgence de la santé publique du CanadaRoles for the Health Sectorin Advancing Health Equity in Public Policies8 th Global Conference for Health PromotionPlenary: Health Promotion and Closing the Health Equity GapDr. Gregory TaylorDeputy Chief Public Health Officer of CanadaTuesday, June 11, 2013Helsinki, FinlandPublic Health Agency of Canada | Agence de la santé publique du Canada


Overview• Advancing Health Equity: Canadian Context andthe Ottawa Charter• Roles for the Health Sector• Success FactorsPublic Health Agency of Canada | Agence de la santé publique du Canada 62


“The fundamental conditions andresources for health are:PeaceShelterEducationFoodIncomeA stable ecosystemSustainable resourcesSocial justice and equity.”-Ottawa Charter for Health Promotion,1986Public Health Agency of Canada | Agence de la santé publique du Canada 63


Dr. Andrés PetrasovitsPublic Health Agency of Canada | Agence de la santé publique du Canada 64


A history of socialdemocracy1989: Canada Child Tax Benefit1966: Medicare, Pension Plan1952: Old Age Security Program1940: Unemployment InsuranceProvincial/Territorial antipovertystrategies in place65


Canadian Context• Not all health trends improving• Persistent inequalities – income, sex and gender,geography• Aboriginal populations face particular challenges• Change drivers (e.g.: demographics, globalization,technology)Public Health Agency of Canada | Agence de la santé publique du Canada 66


Global Lessons: Reducing Inequalities – Roles for the HealthSectorInternational Efforts involving Canada• Lessons Learned from CanadianExperiences with Intersectoral Action toAddress Determinants of Health: 8 casestudies• Health Equity Through IntersectoralAction – analysis• Addressing Social Determinants ofHealth Through Intersectoral Actions• A Cross-Country Analysis of theInstitutionalization of Health ImpactAssessment• 2011: World Conference on SocialDeterminants of Health;• UN Non-Communicable DiseasesSummitPublic Health Agency of Canada | Agence de la santé publique du Canada 67


Advancing Health Equity: Roles for the Health SectorLeadPartnerEnableAdvocateMitigateCheerleadPublic Health Agency of Canada | Agence de la santé publique du Canada 68


Lead• Mexico National Agreement forHealthy Food• Cholera prevention and control inHaiti• Act Now BCPublic Health Agency of Canada | Agence de la santé publique du Canada 69


Partner• Oportunidades – Mexico• Cash Transfer Programs –Brazil, Chile• Manitoba Child HealthPublic Health Agency of Canada | Agence de la santé publique du Canada 70


Enable• New Zealand – data collection andreporting• Canada – Pathways to Health Equityfor Aboriginal Peoples• Canadian Council on SocialDeterminants of HealthPublic Health Agency of Canada | Agence de la santé publique du Canada 71


Advocate• South Australia – Health in AllPolicies approach• Thailand – Health ImpactAssessment• Quebec Public Health LawPublic Health Agency of Canada | Agence de la santé publique du Canada 72


Cheerlead• Sri Lanka – mid-20 th Centuryrapid transition• Provincial and Territorial antipovertystrategiesPublic Health Agency of Canada | Agence de la santé publique du Canada 73


Mitigate• Health Equity ImpactAssessments• BC Tri-Partite AgreementPublic Health Agency of Canada | Agence de la santé publique du Canada 74


Success Factors and Considerations• Intersectoral Approaches• Citizen ParticipationPartnerLeadEnable• Space for Deliberation• Transparent DocumentationAdvocateCheerleadMitigate• Integrated Measurement andMonitoring• Learning• OpennessPublic Health Agency of Canada | Agence de la santé publique du Canada 75


"It's amazing how much can be accomplished if noone cares who gets the credit.”Public Health Agency of Canada | Agence de la santé publique du Canada 76

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