One Conference, Two Declarations

“Civil society is fantastic in the sense that they push us”


World Conference on Social Determinants of Health

Rio de Janeiro, October 19-21, 2011

World Health Organization (WHO)


Guest post by Margot Lettner

With not one but two Declarations on the floor as the Conference closed, Marie-Paule Kieny, Assistant Director-General, WHO, described the relationship between U.N. agencies and social movements.

On October 21, 2011, the Rio Political Declaration on Social Determinants of Health was signed by Heads of Government, Ministers and government representatives of Member States attending the Conference. The declaration represents a collaborative imagining, negotiating and drafting process that began this spring as the Conference discussion paper took shape, then continued over the summer as the first iteration of the final agreement was circulated.

Not surprisingly, the declaration picks up all five of the Conference themes that emerged from these pre-conference consultations – better governance, participatory policy-making and implementation, reorientation of the health sector, strengthened global collaboration, and enhanced monitoring and accountability for results. However, these themes aren’t exclusive; the declaration is clear that they illustrate but don’t define its scope of practice.

From its title on, the positioning of the Rio declaration is significant in three respects. It is a “Political Declaration” of political will by Member States, one that sees health equity as a “shared responsibility” that means taking global action to achieve “all for equity” and “health for all”:

Our common values and responsibilities towards humanity move us to fulfill our pledge to act on social determinants of health. We firmly believe that doing so is not only a moral and a human rights imperative but also indispensable to promote human well-being, peace, prosperity and sustainable development.

In the roundtable discussion, Dr. Purnima Mane, Deputy Executive Director, Assistant Secretary-General, UNFPA, noted “the resolution is a peer-group kind of pressure.”

The declaration also legitimizes the threat of  the current global crisis that has mobilized civil society organizations and citizens in occupying actions worldwide:

The current global economic and financial crisis urgently requires the adoption of actions to reduce increasing health inequities and prevent worsening of living conditions and the deterioration of universal health care and social protection systems.

Finally, it signals an emerging consensus or pointed reiteration of support for five specific priorities or best practices ranging from new ways for people to talk with their government, to the ethics of public-private partnership, to health quality.  There is a sense here of engagement with a renewed social contract.

First, governance should not only be inclusive and transparent, it should “engage early” with civil society and the private sector “safeguarding against conflicts of interest.” Public health is an essential partner in health care whose capacity must be strengthened. Primary care should be “comprehensive and integrated” as part of “high quality, promotive, preventive, curative and rehabilitative health services throughout the life cycle.” Equity should be integrated in the design and delivery of health services and public health programmes.  Gender-related aspects and early childhood education should be given special attention in policy and service delivery. And “social protection floors” should be strengthened through the work of both the U.N. and the International Labour Organization.

These may be “statements of nice intentions,” as one participant said.  Public interest civil society organizations and social movements attending the Conference issued an “alternative declaration” on October 18, Protecting the Right to Health Through Action on the Social Determinants of Health. This declaration is clear that sustainable development is in crisis:

Behind the immediate determinants of health … lie the deeper structural determinants including unequal power relations and unequal access to resources and decision making. Widening inequalities and institutionalized discrimination across axes of class, race, gender, ethnicity, caste, indigeneity, age and ability contribute to the impossibility of good health.

Five of the ten “urgently required actions by Member States and WHO” critique our global economic order.  “The clout of finance capital, its dominance of the global economy, and the origins and consequences of its periodic collapses” must be recognized, as well as how global trade regulation shapes health inequalities.  Global speculation must be controlled and progressive taxation used to finance action on social determinants of health.  Finally, how “unregulated and unaccountable transnational corporations and financial institutions constitute barriers to Health for All” must be documented.

For the first time during the Conference, a plenary session took on real meaning as participants and panelists opened up the discussion.  Some felt the WHO declaration watered down the 2008 recommendations of its own Commission on the Social Determinants of Health.  Some saw the declaration as a tool, a set of talking points in an iterative process of influence and change.  Some considered it inconsequential, feel-good puffery.  Some pointed to what was left out, for example, trade, climate change, the unsustainable and amoral pattern of South-subsidization of North-consumption.

William Lacy Swing, Director-General, International Organization for Migration, highlighted the declaration’s silence about the massive displacement that has made 740 million people into migrants, stressing that “the concept of the nation state is changing.”  He couldn’t have underscored the shifting fundamentals, the emerging inequalities, the accelerating damage, any better.

Or the imperative to understand the context of our problems, decide what we value and act.  Differences aside, both declarations name or suggest many of the same threats.  Global economic structures with crushing social consequences.  Diminishing quality of life and well-being.  The impossibility of sustainable development without health in all policies.  And they advocate many of the same solutions.  Democratizing health governance. Ethical conduct and conflict of interest protocols.  Primary health care with public health capacity. Equity, with express recognition of women and indigeneous peoples. Social protection, labour and employment standards.  Early childhood education. The need for disaggregated, stratified, population-based data. Significantly, both declarations show independent yet workable congruence between their five action areas.

Sérgio Cabral Filhio, Governor of the State of Rio de Janeiro, pointed to the black canvas walls of the Conference tent and suggested that if we could all see the ocean outside, we could imagine better things. If optimism is an act of political resistance, as another participant reminded us, perhaps we can.



Margot Lettner is Principal, Wasabi Consulting and an Associate of The Wellesley Institute. She is currently in Rio de Janeiro as a delegate to the World Conference on Social Determinants of Health. In 2010, she facilitated WHO’s pre-conference Advisory Group consultation on social determinants of health. She is also an editor of Influency Salon, a magazine of contemporary Canadian poetry. She can be reached at