Over the years, efforts to improve health in Nigeria both at the federal and state levels have traditionally looked to the health care system as the key driver of health and health outcomes. However, in recent times there has been increased recognition that improving health and achieving health equity will require broader approaches that address social, economic, and environmental factors that influence health.
These nonmedical needs or social health indicators are intricately linked to health. In fact, unaddressed nonmedical needs often result in poorer health and increased healthcare costs.
Social determinants of health are the conditions in which people are born, grow, live, work and age.1 They include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care.
Eze Onyekpere, whose organisation, the Centre for Social Justice (CSJ) Nigeria is working to achieve universal access to health for Nigerians said addressing social determinants of health is important for improving health and reducing health disparities.
He said that though health care is essential to health, it is a relatively weak health determinant. In fact, research shows that health outcomes are driven by an array of factors, including underlying genetics, health behaviours, social and environmental factors, and health care.
While there is currently no consensus in the research on the magnitude of the relative contributions of each of these factors to health, studies suggest that health behaviours, such as smoking, diet, and exercise, and social and economic factors are the primary drivers of health outcomes, and social and economic factors can shape individuals’ health behaviours. For example, children born to parents who have not completed high school are more likely to live in an environment that poses barriers to health such as lack of safety, exposed garbage, and substandard housing. They also are less likely to have access to sidewalks, parks or playgrounds, recreation centers, or a library.
Further, evidence shows that stress negatively affects health across the lifespan5 and that environmental factors may have multi-generational impacts.6 Addressing social determinants of health is not only important for improving overall health, but also for reducing health disparities that are often rooted in social and economic disadvantages.
The programme manager of the USAID-SCALE Improving the Realization of the Right to Health in Nigeria project, Martins EKE said policies and practices in non-health sectors have impacts on health and health equity.
“For example, the availability and accessibility of public transportation affects access to employment, affordable healthy foods, health care, and other important drivers of health and wellness. Nutrition programmes and policies can also promote health by supporting broader efforts aimed at the production and consumption of healthy foods,” Eke said.
While everyone might agree in principle that health, well-being, and equity are desirable, there are fewer consensus on where health ranks among life goals and values. Empirical observations of what people actually do—actual norms—suggest that there is no universally accepted—or practiced—culture of health in Nigeria. Many people might view health not as a primary good or an end in itself but as a means to attain other life goals, such as financial security, personal safety, respect in one’s community, and fulfilling relationships with family and friends. Those who are struggling to raise a family on minimum wages or with everyday threats of Boko Haram or bandits might be too preoccupied with survival to make health a high priority.
Alternatively, creating a culture of health can mean producing the structural conditions that improve the health of Nigerians. This is an important goal and more feasible than establishing health as a national norm. Actions that improve health are possible, regardless of whether health is everyone’s most important value. For example, it might be easier to garner support for better schools than to convince people that education should be improved for the purpose of enhancing their health. Population health is likely to improve with better education, regardless of the underlying motivation.
Again, access to safe drinking water and adequate excreta disposal facilities in Nigeria is problematic. More than half of the population have neither access to safe water nor to excreta facilities. Available data indicates that only 48% of households in Nigeria have access to improved drinking water sources, with access twice greater in urban than rural areas. While safe drinking water is available to 67% of urban dwellers, the figure for rural inhabitants is only 31%. An even lower number, 44%, have access to adequate sanitation coverage. Disaggregated figures show that 36% of rural dwellers have access, compared to 53% of urban residents.
Shortage of safe drinking water sources and adequate excreta facilities contribute to high morbidity and mortality in Nigeria, particularly among children. For instance, schistosomiasis or snail fever, which typically afflicts people without access to safe water and sanitation and whose daily activities bring them into direct contact with infected water sources, is common in some parts of the country. The disease ranks second to malaria as a source of human morbidity and mortality in tropical countries.
Given that many of the serious diseases affecting its people such as malaria, TB and schistosomiasis originate from unsafe and unhealthy environments, environmental health is of particular significance to Nigeria Tackling the environmental factors that create or exacerbate the conditions responsible for these diseases is therefore a necessary prelude to combating them.
Among the numerous environmental challenges facing the country are soil degradation, deforestation, air and water pollution, desertification, oil pollution, loss of arable land and rapid urbanization. The most significant of these problems is pollution arising from oil exploration and production, particularly in the Niger Delta region. Residents of communities in close proximity to the source of pollution have suffered greatly as a result of exposure to oil spills, gas flaring, contamination of food and water sources, and loss of arable land and livestock.
“Addressing the social determinants of health at the level of public policy requires political action,” the Lead Director of CSJ, Eze Onyekpere said.
The most ambitious action agenda, and the one most focused on human health, well-being, and equity, is the agenda set by human rights, as articulated in the primary international human rights declarations and treaties, most centrally the Universal Declaration of Human Rights; the International Covenant on Economic, Social, and Cultural Rights; the International Covenant on Civil and Political Rights; the Convention on the Rights of the Child; and treaties prohibiting racial and gender discrimination.
The Universal Declaration of Human Rights is an aspirational document adopted without dissent by the members of the United Nations in 1948. At its core, it provides that human rights are birth rights—that is, rights all people have at birth by virtue of being human—and generally require the state to treat all humans equally and consistent with human dignity.
Human rights are the dominant international source of norms for governments’ responsibilities to their populations and increasingly of private actors including corporations and nongovernmental organizations. These norms include health rights, especially those protecting the health of populations, defined in the Constitution of the World Health Organization (WHO) as the right to “the highest attainable standard of health.”
As explained in other foundational human rights documents, human rights have at least two other notable characteristics: “All human rights are universal, indivisible and interdependent and interrelated;” and it is the responsibility of governments to respect, protect, promote, and fulfill human rights.
Human rights are sometimes mistakenly thought to protect only individual freedoms, such as freedom of thought and conscience and freedom from slavery and torture. But they are best seen as social responsibilities. The International Covenant of Economic, Social, and Cultural Rights, adopted by the United Nations in 1966 and in force since 1976, imposes duties on the government to respect, protect, promote, and fulfil economic and social rights. These include the right to education, the right to water, the right to work, the right to just and favourable conditions of work, the right of equal access to public services, the right to social security, and “the right to a standard of living adequate for one’s health and well-being, including food, clothing, housing and medical care and necessary social services.”
The human rights framework has several advantages as a unifying force for pursuing action on the social determinants of health. First, it demands attention to all human rights, and actions to protect almost all specific human rights necessarily address the social determinants of health. The synergy between health and human rights makes clear that health depends not only on medical care and lifestyle choices but on all policies that affect well-being and equity.
Second, the human rights framework does not require universal acceptance of health as the preeminent goal of social policy. People who disagree about whether health is a primary good or an instrumental good might still agree on the need to fulfill other human rights, such as education, employment, social security, and equality. Advocates for these separate goals are likely to press for changes that can improve health, even if they are unaware of the social determinants of health.
As better policies are adopted, the public might come to enjoy and expect health, well-being, and equity, regardless of the priority placed on health itself. The culture of health can play a critical role by deepening society’s commitment to health in the enduring human rights movement.
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