INTEGRATING SOCIAL

DETERMINANTS OF
HEALTH IN THE
UNIVERSAL HEALTH
COVERAGE MONITORING
FRAMEWORK
Dr. Jeanette Vega
Dr. Patricia Frenz
Social Inclusion towards Universal Health Coverage
PAHO Webinar Series on Universal Health Coverage
February 3, 2014
OBJECTIVE AND OVERVIEW
UNIVERSAL HEALTH COVERAGE AND THE POST-2015 AGENDA
1
SOCIAL DETERMINANTS OF HEALTH AND THE UHC FRAMEWORK
2
PROPOSAL TO INTEGRATE SDH IN UHC MONITORING
3
To understand that UHC as a global development health goal
embraces SDH and equity.
HEALTH IS
A
PRECONDI
TION FOR,
AN
OUTCOME
, AND AN
INDICATO
R OF
SUSTAINA
BLE
DEVELOP
MENT
HEALTH ENABLES
SUSTAINABLE
DEVELOPMENT
Every human being is entitled to the
enjoyment of the highest attainable
standard of health conducive to living a
life in dignity.
75% of health outcomes depend
on living and working conditions.
Healthy populations mean greater labor
participation and productivity.
HEALTH IS
A RIGHT
HEALTH IS
SOCIALLY
DETERMINE
D
HEALTH
CONTRIBUTE
S TO
DEVELOPME
NT
UHC AN
UMBRELLA
GOAL
UNIVERSAL HEALTH
COVERAGE
Health promotion, prevention,
treatment, financial risk protection.
HEALTHY LIVES AT ALL
STAGES
Child survival, maternal survival,
MDG6, adolescent health, NCD
burden reduction.
SUSTAINABLE
WELLBEING FOR ALL
Poverty eradication, health,
education, nutrition, environment,
security, etc.
HEALTH
SECTOR
CONTRIBUTI
ON
OTHER
SECTOR
CONTRIBUTI
ONS
POST-2015 DEVELOPMENT
AGENDA: WELLBEING FOR ALL
THE CONTRIBUTIONS OF THE
HEALTH SECTOR AND OTHER
SECTORS
THE RIGHT TO HEALTH
EMBEDS SDH

PROGRESSIVE REALIZATION:
Maximum available resources, deliberate and concrete steps.
Indicators and targets.
DETERMINANTS HEALTH CARE
HIGHEST
ATTAINAB
LE
STANDAR
D OF
HEALTH
Living and working
conditions
Education
Water
Sanitation
Food
Nutrition
Housing
Healthy environment
Information
National public health
plan and strategy
AVAILABILITY QUALITY ACCEPTABILITY ACCESSIBILITY
Universal coverage
Equitable distribution
of goods and services
Maternal and child
health
Immunization
Prevention and
control of disease
Essential medicines
Education and
training
FULFILL
Frenz 2009.
RESPECT PROTECT
UNIVERSAL HEALTH
COVERAGE: WHAT DOES IT
MEAN?
Core
Tenets:
ALL PEOPLE CAN ACCESS THE HEALTH
SERVICES THEY NEED WITHOUT
INCURRING FINANCIAL HARDSHIP.
Definition:
EQUITABLE DISTRIBUTION
OF HEALTH CARE AND,
ULTIMATELY, HEALTH
WHO World Health Report 2010
1. UNIVERSAL
2.
COMPREHENSI
VENESS
3.
AFFORDABILIT
Y
INPUTS &
PROCESSE
S
Health Financing
Health Workforce
Infrastructure
Information
Governance
Service Delivery
OUTPUTS
Service Access
and Readiness
Service Quality
and Safety
Service
Utilization
Prepaid Funds
OUTCOME
S
Coverage of
Interventions
Coverage with a
Method of
Financial Risk
Protection
Risk Factors
IMPACT
Health Status
Household
Financial
Wellbeing
Responsiveness
THE UHC FRAMEWORK IS
DEVELOPING, BUT
Source: WHO (2011). Monitoring, evaluation and review of national health strategies.
SOCIAL DETERMINANTS
LEVEL AND DISTRIBUTION (EQUITY)
EQUITY AND SOCIAL
DETERMINANTS NEED TO BE
CENTER STAGE
Source: WHO & World Bank (2013). Monitoring progress towards UHC at country and national levels. A framework.
FULL SPECTRUM OF INTERVENTIONS
ADDRESSING HEALTH NEEDS
COMMUNICABLE, MATERNAL,
PERINATAL,
NUTRITIONAL CONDITIONS (MDGS)
NON-COMMUNICABLE DISEASES,
MENTAL HEALTH, INJURIES (CCIS)
Promotion and
Prevention
Family planning
Pregnancy care
Immunization
Water and sanitation
Nutrition
HIV
Malaria
Neglected Tropical
Diseases (NTD)
Treatment and
Care
Delivery
Sick children
HIV
TB
Malaria
NTD
Promotion and
Prevention
Non-communicable
diseases (NCD),
including cancer
Mental Health
Injury
Occupational health
Environmental health
Treatment and
Care
NCD, including
cancer
Mental health
conditions
Injury
Rehabilitation
Palliation
Indicators of Intervention Coverage Among Population in Need
(with equity and quality [effective coverage] dimensions)
HOW TO INCLUDE SDH IN
THE UHC MONITORING
FRAMEWORK
Define key indicators of social
determinants of health, amenable to
action from other sectors.
Stratify the core set of health
outcomes and health coverage
indicators by equity relevant
markers (income, education,
gender, geographic).
STRATIFY
ALL
INDICATORS
INCLUDE SDH
INDICATORS
+
DEFINING AND STRATIFYING
HEALTH INDICATORS
Data source: Hosseinpoor et al. Forthcoming.
0
20
40
60
80
100
Quintile 1 (Poorest) Quintile 2
B
i
r
t
h
s

A
t
t
e
n
d
e
d

B
y

S
k
i
l
l
e
d

H
e
a
l
t
h

p
e
r
s
o
n
n
e
l

(
%
)

Country A
Country B
Country C
A
B
C
C
Health
Indicator
Correlation Coefficient Between
Economic-related Inequality
*
and
Other Dimensions of Inequality
Education-
related
Inequality
**

Urban/Rural
-related
Inequality
***

Sex-related
Inequality
****

Adequate
Physical
Activity
0.25 0.46 -0.03
Healthy Diet 0.31 0.83 -0.15
Non-harmful
Use of
Alcohol
0.55 0.71 0.27
Non-use of
Tobacco
0.55 0.81 -0.33
*Calculated using pooled data from 30-37 countries

, WHS, 2002-2004.
INEQUALITY IS MULTIDIMENSIONAL
INEQUALITY IS MORE THAN CONCERN FOR THE
MOST VULNERABLE
DEFINING AND STRATIFYING
HEALTH INDICATORS
0
20
40
60
80
100
Quintile 1
(Poorest)
Quintile 2Quintile 3Quintile 4Quintile 5
B
i
r
t
h
s

A
t
t
e
n
d
e
d

b
y

S
k
i
l
l
e
d

H
e
a
l
t
h

P
e
r
s
o
n
n
e
l

(
%
)

Country A
Country B
Country C
A
B
C
C
Health
Indicator
Correlation Coefficient Between
Economic-related Inequality
*
and
Other Dimensions of Inequality
Education-
related
Inequality
**

Urban/Rural
-related
Inequality
***

Sex-related
Inequality
****

Adequate
Physical
Activity
0.25 0.46 -0.03
Healthy Diet 0.31 0.83 -0.15
Non-harmful
Use of
Alcohol
0.55 0.71 0.27
Non-use of
Tobacco
0.55 0.81 -0.33
*Calculated using pooled data from 30-37 countries

, WHS, 2002-2004.
INEQUALITY IS MULTIDIMENSIONAL
INEQUALITY IS MORE THAN CONCERN FOR THE
MOST VULNERABLE
Data source: Hosseinpoor et al. Forthcoming.
KEY INDICATORS OF SDH:
THE INDICATORS OF OTHER
SECTORS
Michael Marmot Proposed Four with a Life Course
Perspective:
Data source: Marmot M. Universal health coverage and social determinants of health. Lancet. 2013; 382(9900):12278.
Early Child
Development at
Age 5
% of Young
People Not in
Employment or
Training
Social Isolation
or Poverty
(Both)
in People Older
Than Working-
age
An Adult
Poverty Measure
1
3
2
4
WHO INITIAL CORE SET OF
SDH INDICATORS
Domains Potential Indicator
Education
% of mothers of children under 5 with incomplete primary
education.
Early Child
Development
Q1/Q5 Early child development index.
Employment Unemployment rate in population <45 years of age.
Poverty Poverty rate in people >65 years of age.
Income
Distribution
Gini coefficient.
Connection of
Social Policies
% of families with baseline data on household, education,
income, labor conditions.
% of families with access to public subsidies.
Data source: Hosseinpoor et al. 2014. forthcoming.
SUMMARY
UHC is the health sectors fundamental contribution to health,
well-being and sustainable development.
UHC should be an umbrella health sector goal in the post-2015
agenda: the foundation is a strong health system, aligned with
other sectors around shared goals.
Addressing the social determinants of health (SDH) is critical to
both the equitable pursuit of healthy lives and the provision of
health services for all (UHC).
Thus, SDH indicators should be included in the UHC monitoring
framework.