Living In Auspicious Times: health as a human right

World Conference on Social Determinants of Health

Rio de Janeiro, October 19-21, 2011

World Health Organization (WHO)

Margot Lettner

“We live in very auspicious times for participation. It sails the winds of history.”

Among the many papers I picked up at the Rio Conference is one authored by Bernardo Kliksberg, Honorary Professor, University of Buenos Aires. Reading it at Galeo Airport – one long wait for Delta Flight 60 and the wilting salgados have lost all savoury appeal – I came across his simple way of seeing how social participation can transform public policies that fight health inequities.

A world conference hosted by a United Nations agency such as the WHO, like the Rio Conference that just ended, is an event: 1,200 delegates (450 representing 60 Member States, 750 experts and civil society members); a big tent; a brand; star moderators in Zeinab Badawi and Riz Khan from BBC World News and Al Jazeera English, respectively; a president, assorted government ministers, a chorus of independent voices. Script, actors, audience and certainly patrons are decided far in advance and – in this particular theatre tradition – improvisation is limited.

Formal planning for the Rio Conference began at least a year in advance, with an advisory group of about 20 health policy experts drawn from WHO Member States who met on Wasan Island, Ontario in September 2010 to brainstorm themes. But its real genesis was even earlier. The Commission on Social Determinants of Health chaired by Sir Michael Marmot reported to the WHO in 2008, Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Then in 2009, the World Health Assembly passed Resolution 62.14 requiring the WHO to follow up on the report’s recommendations.

By this spring, the draft conference Discussion Paper was open for comments. Member States began negotiating the text of the Rio Declaration this past summer. The conference agenda was set by September.

So by the time we all arrived in Rio, much of the writing was already on the page.

It’s important to keep this context in mind while being there, as well as when reflecting later on what happened. As a participant, your real opportunity to contribute is limited. Only one plenary session opened up for comments and questions from the floor; and this was the final plenary that presented the just-approved Rio Declaration to delegates. It was electric but cut short because some panelists had to leave. While the smaller breakout sessions that ran during the conference included some moderated discussion, the relatively large number of participants, over 100 in each group, limited meaningful conversation and learning.

The conversations with most meaning, then, that held the most provocative and novel ideas and experiences, that offered the most hope as well as the deepest disquiet, happened away from the podium. Here are the conversations I heard most often as I talked with people; and which also came to resonate the most with me.

We need to name and formalize the right to health as a human right. We need new forms of civil society and broader citizen participation in public policymaking, an activist agenda that not only reclaims and reconfigures the democratic, but also resists the public service’s chronic reluctance to change. We need to join up agendas: as the WHO’s Commission on Social Determinants of Health argued in Closing the Gap in a Generation, we must make common cause with people active in, and affected by, sustainable development, the environment and climate change, education from early childhood to learning across the lifecycle, employment and working conditions and anti-poverty campaigns.

We need a global health ethics that mandate protocols for health governance, given a pre-eminently market-driven global economic model weak on equity and accountability. We need to use the declarations tabled at Rio – both the official and the alternative ones – to develop local action plans based on local evidence and local mechanisms for policymaking, practice and monitoring. And we need to reconnect our priorities with frontline health: to resource and measure the basics of primary health and public health and the people who practice them. Building the “we” as the foundation to this work – an inclusive, participatory, and activist voice – is imperative.

“All for equity,” the Rio rally, faces immediate challenges within the UN itself. The WHO has committed to provide technical assistance to Member States on how to implement a determinants approach, on “what works, what doesn’t,” chiefly through its regional offices. It also raises its own capacity as an issue. First, the WHO and other UN agencies have not always worked collaboratively on determinants-based issues (as the conference closed on October 21, agency representatives met in Rio to explore a better way – a sign of change?)

Second, and of greater concern, some Member States continue to press the WHO hard to restructure its current governance, partnerships and operations, believing that their funding entitles them to greater say over WHO decisions and activities. What non-sovereign influences may also come through this back door; and how transparent will their identity and influence be? Health as a commodity, health care as a commercial transaction – whose values are valued, who is accountable? WHO is already experiencing financial pressures, in part from lagging Member contributions, that have resulted in staff reductions. The UN and its agencies are not only an expression of our international political will towards consensus or disagreement, they also embody our international public service.

In a post-Rio presentation hosted by The Wellesley Institute on December 6, I will be talking about these themes in greater detail, including my visit with the Fundação Oswaldo Cruz (FIOCRUZ), the public health foundation partnered with Brazil’s Ministry of Health. Most importantly, the session will be open for conversations about what concrete work can be done now to move determinants-based approaches into practice here, in Ontario; as well as where the political and social openings are that will build momentum, advocates and better outcomes across communities and policy sectors. Event details will be posted on the Wellesley Institute website shortly.

Here are some other significant ideas, achievements and events profiled at the conference that may spark new collaborations on December 6.



1.     It’s the wealth distribution model, not necessarily the economic model, that influences health status – Luiz Odorico Monteiro de Andrade, National Secretary for Strategic Planning and Participation, Ministry of Health, Brazil
2.     A strategic plan is a social determinants of health plan. The ideal plan, of course, would place communities at the centre of the plan with services around them – Kevin Buckett, Director of Public Health, South Australian Department of Health

3.     Why don’t we report social indicators daily just as we do economic indicators? – David Sanders, University of the Western Cape



1.     WHO launched its new global community of practice tool for social determinants (information at Membership is free and gives users access to downloadable content, conversation forums, opportunity to contribute evidence, examples, and resources and a newsletter.

2.     People’s Health Movement (PHM) launched its new global Right to Food and Nutrition Watch 2011 as a companion advocacy, accountability and research-into-practice tool to its just-released Global Health Watch 3: An Alternative World Health Report (,,


Frontline health, Brazilian milestones

1.    In 1988, health care as a citizen’s right and corresponding duty of the state was added to the Brazilian Constitution.

2.    Over the past 40 years, Brazilian health sector reform has been driven by civil society rather than by governments, political parties or international organizations. Social participation in health sector strategies, policies, implementation and evaluation is constitutionally legislated through health councils and conferences at all three levels of government, with membership made up of 50% users, 25% health workers and 25% health managers/providers. A proportion of municipal or state health budgets is a participatory budget and decided by citizens through popular vote. ParticipaSUS, the national policy for strategic and participatory management, continues to integrate social participation in health decision making.

3.     Bolsa Família, Brazil’s social security system with an intersectoral policy focus, includes a conditional cash transfer program for families that supplements household income and is tied to school enrolment and use of primary health care services such as vaccinations. R$13 billion was distributed to 10.5 million families in 2008, with over 90% of payments going directly to mothers. (For six detailed papers that critically examine outcomes and opportunities in Brazil’s health policies, see The Lancet, “Health in Brazil,” May 2011.)


The case for evidence

1.  It’s radical to measure, and measuring the right thing is powerful. What gets measured, gets done – Michael Marmot, University College, London.

2.     The rub of inequities lies in their invisibility and their magnitude. For better data about determinants we need disaggregated measures that trend over time; that reflect increasingly real-time results; that capture outcomes beyond survival (e.g., morbidity, disability, mental health and other burdens of ill health, as well as the benefits of well-being); and that cluster stratifiers so that relationships among specific determinants are tested. To get these data we need population-based surveys, health equity audits and dissemination portals that combine information with advocacy – Hoda Rashad, Social Research Centre, The American University in Cairo.

3.     Decentralizing policymaking and program delivery to municipalities results in the creation of nuanced local data critical to planning and measuring but often difficult to capture in larger data sets – Maria Guzenina-Richardson, Minister of Health and Social Services, Finland.


Margot Lettner is Principal, Wasabi Consulting and an Associate of The Wellesley Institute. She has just returned from Rio de Janeiro as a delegate to the WHO World Conference on Social Determinants of Health. In 2010, she facilitated WHO’s pre-conference Advisory Group consultation on social determinants of health. The title quote is taken from “Strategies and Methods for Promoting Social Participation in the Development and Implementation of Public Policies to Fight Health Inequities,” Bernardo Kliksberg, World Health Organization (WHO), 2011, p.24. She is also a board member and editor of Influency Salon, a magazine of contemporary Canadian poetry. She can be reached at