Lecture 6: Social Determinants of Health and Development February 13, 2012
“Upstream” Determinants (Ultimate Causes) see lecture 5 for its definition*
Political, Economic, and Environmental Factors
Malaria Risk (for example) as a function of:
1. Environmental change
2. Economic inequality
3. Political economy
4. Health care systems
5. Global health care research
All these factors indicate how these ultimate factors cause people to be affected by malaria
A term broadly describing unjust, aberrant and corrupt social structures characterized by poverty and extensive social inequality,
including racism and gender inequality
Structural violence is violence exerted systematically - that is, indirectly (and directly) - by everyone who belongs to a certain social
order (Farmer 2004)
o Corruption of social structures
o An example of ultimate causes
Quiz #1: “Structural violence” does not include:
a) Social caste/class system
b) Historical racial oppression
c) Female income disparity
d) None of the above
WHO (2007) Key Messages: Residential and Relational Community
1. The integrity and accessibility of physical space in which children can explore and play is critical for all three domains of ECD.
2. The physical, socioeconomic, and service aspects of residential communities all strongly influence ECD.
3. Relational communities are a primary source through which families derive values, norms, and social support.
4. Bonding within relational communities may result in social exclusion (even conflict and discrimination) between them.
5. Gender norms and roles are often rooted in the social beliefs of relational communities, thus addressing gender equity at this level is
WHO (2007) Key Messages: ECD Programmes and Services
1. Public investment in early childhood programs and services is extremely powerful, with far greater returns to society occurring in many
areas (education and beyond) and throughout the life course.
2. The ultimate goal of every society should be universal access to quality services and programmes that are built on existing service
infrastructure (e.g., health care system).
3. There are multiple entry points for ECD services and programmes, including health care systems, community-based childcare, and
4. Health care systems (HCS) are in a uniquely powerful position to contribute to ECD, since they are often the first system-of contact for
children and mothers.
5. HCSs can ensure that development programmes address ECD in a comprehensive manner, combining health and nutrition with early
learning; addressing the needs of children and of families.
6. Current effective strategies through HCSs should be widely implemented in resource poor countries.
7. Those responsible for ECD programmes and services must develop partnerships with families and tailor services to the needs of those
8. Programmes and services should be built upon understandings of quality and equity, and should be monitored in these regards.
9. Governments have a central role to ensure that ECD programmes and services are fully integrated into social protection policies.
WHO (2007) Key Messages: Regional and National
1. Monitoring variation in children’s developmental outcomes at the regional level provides insights regarding ‘nurturant’ macro-
2. Effective governance for ECD programs and services generally takes place at the regional level.
3. ‘Indirect’ (social/economic) policies that affect ECD are also often enacted at the regional and national levels.
4. National governments must be held responsible for upholding their commitments to the CRC and the MDGS.
5. Investing in ECD is an integral component of a nation’s long-term economic and social strategy; underinvestment in ECD undermines
societal progress. 6. “Child and family friendly” societal investment strategies can be enacted regardless of the relative level of the per capita gross domestic
product (GDP) of a society.
7. Requirements of international conventions, such as the CRC, International Labour Organization (ILO) Global Reports, and Convention on
the Elimination of All Forms of Discrimination against Women (CEDAW), can be used as levers for change at national levels.
8. Child survival and ECD are inseparable; investments that bolster ECD tremendously increase child survival while simultaneously
improving the future life chances of all children.
WHO (2007) Key Messages: Global
1. Current global momentum is creating new opportunities and convergence of disparate initiatives regarding ECD
2. Alliances should be encouraged between all individuals and organizations dedicated to child well-being and social welfare
3. Because of its global responsibility in population health, the WHO should strengthen its commitment to ECD as a key social determinant
4. The international community must establish a unified mechanism for monitoring child development between communities and societies,
and over time.
5. The CRC’s new General Comment #7 on Implementing Rights in Early Childhood creates a strong opportunity to hold state parties
responsible for equity in ECD and social determinants of ECD.
Irwin et al. (2007)
General Comment #7 on Implementing Rights in Early Childhood of the CRC (2005) creates an opportunity to hold “state parties”
responsible for the physical, social/emotional, and language/cognitive development of young children, as well as eradicating child
Defined as most productive activity of children (production of commodities for market), but “excludes the activities of children 12 yrs
and older who are working only a few hours a week in permitted light work and those of children 15 years and above whose work is not
classified as ‘hazardous’” (ILO 2002)
Data from 2002 compiled by the ILO: approx. 246 million children engaged in some form of child labour, with 171 million of these
working in hazardous situations or conditions
Majority (over 127.3 million) concentrated in the Asia-Pacific region, followed by Sub-Saharan Africa (48 million) and Latin America and
the Caribbean (17.4 million)
Boys slightly outnumber girls (132 million versus 113 million), but even more disproportionately (95.7 million compared to 74.8 million)
bear the burden of work that is defined as hazardous (ILO 2002)
The CRC compels governments to prioritize childhood and protect the following:
1. The right to survival
2. The right to develop to the fullest potential
3. The right to protection from abuse, neglect, and exploitation
4. The right to participate in family, cultural, and social life
Signed countries agree to provide support and assistance within the framework of these four basic principles.
World Bank & IMF: Structural Adjustment Programme (SAP)
Set of policies introduced to resource-poor nations in 1980s-1990s
Purpose: increase economic prosperity of low-income nations (for the purpose of paying debts to high-income nations)
Involved increasing privatization and decreasing role of government in many aspects of economic and social goals
Included reducing investments in social welfare programmes (education, health care and other services that benefit ECD), as a means
of increasing “efficiency” and spurring economic growth in the resource-poor nations
o Help countries develop; purpose of increasing prosperity
o They we bank loans to help countries develop economically
o Governments cut back on money, by cutting social services in countries
o Had detrimental effects during the 70s-80s
o Effects of SAP within Africa
o Ultimate factors that affected child growth and development
SAPs had huge impacts
Currency devaluation and increased cost of living
Devolution of health sector (and reduction in health workers) led to greater individual responsibility for treatment
Rising income disparity and greater absolute poverty
Economic deprivation led to environmental degradation and diverted resources necessary to address env. risk factors, ie. malaria
Reduced spending on education, ECD programs, social services Worsening women’s health, resulting from uneven allocation of household resources and low status, worsened child/infant health
Associated with increasing rates of malaria, TB, HIV, etc. after the 1980s
Quiz # 2: Which statement is incorrect about SAP:
a) They reduced privatization and increased the role of government in economic development
b) They were intended to bring prosperity
c) Increase higher cost of living
d) Led to higher spending
WHO: Necessary Commitments from Multiple Levels of Society (Irwin et al. 2007)
1. Local, regional, and national governments should incorporate the “science of early child development” into policy
2. In order to a