Renewed health advocacy strategies used by Medical students

Social determinants of health including socioeconomic, cultural and environmental conditions are the main causes of poor health and associated inequities between and among various racial, ethnic, or other demographic groups and countries.2

In response to global political and economic forces, some countries integrate health and human rights into medical education.2 Changing and modifying of social determinants are essential to improve health via transformation of policies, rules, regulations and legislations among various sectors related to public health, business, industry and medicine. However, it is not the sole responsibility of policy makers and institutions to modify these social determinants.2 Subsequent individual advocacy efforts, a change in people’s cultures and beliefs and how they think about the issues can support and modify social determinants of health.2

Health advocacy is “the processes by which the actions of individuals or groups attempt to bring about social and organisational change on behalf of a particular health goal, program, interest or population”.2

“Advocacy has the potential to shape or change policy in a way that impact the health of thousands, if not millions, of people”.2

Communication is the most basic level of health advocacy. Messages are sent to persuade and influence others. Advocacy efforts are more effective and attractive when various tools aid with the communication process such as technological advances including software and associated devices.2

Young adults aged 18 to 29 are disengaged in civil activities. Most young adults lack knowledge of political topics and processes, registering to vote and participation in actions beyond voting.2 They are not involved in political affairs because “they are alienated from the institutions and processes of civil life and lack the motivation, opportunity, and ability to overcome this alienation”.2

Adolescents aged 12 to 17 are a largely untapped resource within communities and can be civically active. They can be involved in community organising and advocacy projects, being provided with opportunities to successfully participate in social change and civic affairs and develop skills into adulthood.2

There are various communication devices which use wireless technology to send information and communicate with other devices across distances.2 Mobile phones are the most common tool of communication devices as they can transmit voice data and send text and multimedia messages. Internet access is available through web-enabled mobile phones. Internet allows access to social networking sites such as Facebook, blogs and twitters which strengthen existing social networks, find new friends and expand networks.2 These technologies allow sharing of information at a faster pace, recruiting more people and using a variety tools to implement the necessary action for social change. Youth advocates can use mobile phones and social networking sites to recruit people to join the cause, organise collective action, raising awareness and shaping attitudes, raising funds to support the cause and communicating with decision makers.2

Social justice curriculum can be integrated as part of medical education.1 There should be a focus on methods which promote critical thinking and self-reflection to guide curriculum development.1 There are several opportunities which can model and teach principles of social justice within a medical school such as site visits during community projects, role playing, reading groups, reflective journaling, small group discussions and use of social media such as mobile phones and social networking sites.1 According to JABSCOM social justice curriculum, education of social justice can be brought about through lectures, group discussions and posting on blogs.1 Following that, implementation involves professional skills development, community services and experimental learning in medical school through public speaking, public policy advocacy, community-based action projects and literature-based research presentation.1 Evaluation includes social awareness and life-long personal growth through self-reflective essays, continuation in learning and actions and pre-/post-program evaluations.1


  1. Hixon, AL, Yamada S, Farmer, PE & Maskarinec GG. Social justice: The heart of medical education. Social Medicine [Internet]; 2013 [cited 2014 Apr 9];7(3):161-168. Available from:…/671/1380‎
  1. Thackeray R & Hunter M. Empoweeing Youth: Use of Technology Advocacy to Affect Social Change. Journal of Computer-Mediated Communication [Internet]; 2010 [cited 2014 Apr 9];15(4):575-591. Available from:

India: Inequalities of health, Dalit Solidarity’s health advocacy strategies

The caste system is a major indicator of health outcomes and requires interventions to change these social structures.6 While caste system is no longer practised in urban areas of India, it still persists in rural India.6 The inherent caste-related inequality continues to dominate reality in Indian society despite the secular, socialistic and democratic principles enshrined in the constitution demand of equality of outcomes.6 Caste system is a social construct and there is hardly any genetic difference among castes.6 The caste system is just a social concept without any genetic concept.6 These social constructs have a stranglehold on human though, perpetuating prejudice and propagating unjust societal structures.6

The National Family Health Survey-III (2005-2006) highlights the caste differentials in relation to health status.6 The lower castes have reduced access to maternal and child healthcare, together with evident reduced levels of antenatal care, complete vaccination coverage and institutional deliveries. There is higher mortality in under-five children among the lower classes.6 The problems in accessing healthcare were higher among lower castes.6 Stunting, wasting, underweight and anaemia in children and adults are higher among the lower castes.6

Dalits continue to face social discrimination and exclusion and are targets of communal violence. It is common for upper castes to assault, rape and murder the Dalits (the untouchables).6 However, these crimes are not investigated and the upper castes are not punished by authorities, despite laws and protection provided by the India government.6

There is a connection between health and human rights. The abuse of human rights can have serious health consequences.6 However, protecting human rights will reduce vulnerability to ill-health by providing freedom from discrimination, rights to health, education and housing.6 The World Health Organisation strongly encourage for a human rights-based approach strategy to address human rights issues and overcome the persistence of discrimination.6

The Dalit Solidarity is an organisation to provide India’s Dalits with the equipments they need to improve their quality of life.1 Thousands of Dalits now have access to quality health care and hundreds of children are provided with opportunities to attend good schools, from elementary through graduate school.1 The Dalit Solidarity advocates tirelessly on behalf of India’s Dalits, to address the discrimination issue of the caste system and untouchables and standing strong for one of the world’s most oppressed populations.1

St. Mary’s Medical camps provide affordable and quality care directly to the rural villagers in Villupuram District.2 St. Mary is a 10 bed health centre, equipped with pharmacy and laboratory facilities.2 There is a physician, two nurses, a pharmacist and laboratory technician.2 Dalit Solidarity provides quality health care for over 1500 patients each month and also operates a First Responder Program to provide first aid in the villages.2

First Responders provide the only available emergency care in the villages.3 There is virtually no emergency transportation service in rural India.3 Patients have to travel by ox cart or be carried by family and friends to the nearest emergency centre.3 First Responders Program provides limited onsite emergency care and stabilise patients until they can be transported to a medical facility.3

Dalit Solidarity has a community health program which focuses on improving the health of rural Indian men, women and children.4 This program provides comprehensive healthcare for rural villagers in Villupuram District. Community health program provides preventative healthcare which is generally not known in rural India.4 Early detection and prevention system is a diagnostic computer software system which allows early detection of diseases among rural populations and provides patients with probable diagnosis and recommendations to physicians, necessity for laboratory testing or appropriate home treatment.4

Dalit Solidarity provides opportunities for quality education.5 The Dalit leadership academy bridge program is a boarding program which provides qualified Dalit youths with one year of intensive training in academics, communications and leadership skills to allow them to succeed secondary school.5 The scholarship program provides more than 200 students with scholarships to attend the academic institution of their choice.5 Community college program provides qualified high school graduates with training opportunities in a variety of fields such as nursing, preschool education, tailoring, computers and automotive mechanics.5

Overall, there are many social determinants contributing to the health of Indians such as cultural factors which affect socioeconomic factors. Strategies and advocacy principles are taken by organisations such as Dalit Solidarity to improve the health of Dalits and provide them equal opportunities and education to succeed in life.


  1. Dalit Solidarity (UN). What we do [Internet]. Dalit Solidarity (UN) [cited 2014 Apr 8]. Available from:
  2. Dalit Solidarity (UN). St. Mary’s Health Care Center [Internet]. Dalit Solidarity (UN) [cited 2014 Apr 8]. Available from:
  3. Dalit Solidarity (UN). First Responders Programme [Internet]. Dalit Solidarity (UN) [cited 2014 Apr 8]. Available from:
  4. Dalit Solidarity (UN). First Responders Programme [Internet]. Dalit Solidarity (UN) [cited 2014 Apr 8]. Available from:
  5. Dalit Solidarity (UN). Education [Internet]. Dalit Solidarity (UN) [cited 2014 Apr 8]. Available from:
  6. The Hindu (India). Caste and inequalities in health [Internet]. The Hindu (India); 2009 [cited 2014 Apr 8]. Available from:

Unequal distribution of wealth globally


Figure 2-2.  Average global wealth variation across countries and regions. Levels of wealth (USD) are measured as wealth per adult.

Figure 2-2 shows the distribution of wealth across the world, varying from one country to another.1Oxfam reports from this year have revealed that nearly half of the world’s wealth is owned by one percent of the world’s population. Whilst some economic inequality is required in a healthy economy to drive growth and to reward those who contribute and work hard in society, such extreme disparity in wealth does the opposite of encouraging this. Extreme economic inequality can lead to the exacerbation of social problems, which have eventual negative impacts on population health.

The richest countries are in North America, Western Europe, include Australia and other Asia-pacific and Middle Eastern countries, highlighted in red. The levels of health in these countries are more than USD$100,000 per adult.1Some European Union (EU) countries such as Portugal, Malta and Slovenia, belong to the “intermediate wealth”group with levels of wealth ranging from USD$25,000 to USD$100,000.1

Countries such as China, Russia, Indonesia, South Africa Brazil, Philippines, Egypt and Iran have levels of wealth ranging from USD$5,000 to USD$25,000.  These nations cover a large area of the world and are also highly populated.The countries with wealth levels below USD$5,000 are in Central Africa and South Asia.1


Wealth Distribution- looking at Africa, Asia-Pacific, China, Europe, India, Latin America and North America

Figure 3 shows that in Africa 91.4% of adults earn less than USD$10,000 in comparison to the world where only 68% earn less than USD$10,000.1 94.4% of adults in India earn less than USD$10,000. But the proportion is 47% in Europe, 58% in China, and 31% in North America. In contrast, only 26% of adults in Europe and 37% of adults in North America earn more than USD$100,000.1


  1. Credit Suisse (Switzerland). Global wealth Databook 2013 [Internet]. Credit Suisse (Switzerland); 2013 [cited 2014 Apr 8]. Available from:
  2. Oxfam. Oxfam briefing paper 2014 [Internet]. Oxfam (Australia); 2014 [cited 2014 Apr 8]. Available from:

WHO Europe- Advocating for Equity in Health delivery

World Health Organisation (WHO) Europe has many strategies to promote health and address the social determinants of health.1 These strategies can be grouped into areas of work such as promoting the health of vulnerable groups, strengthening local-level and sub-national level governance.1

The efforts towards improving health of populations experiencing poverty and social exclusion are undermined by the inability of health systems to provide equity.1 Insufficient  targeting on the determinants of health will also obstruct efforts to improve population health.1

Healthy cites: A powerful movement towards a sustainable solution

Achieving health and equity in the delivery of all local policies


Healthy Cities is a major public health movement and a beacon of hope  for efforts to achieve social justice.1 It is changing the how the local government, communities and individuals think and make decisions about health to create a more equitable and sustainable city.1 There are three prerequisites for city action including vision, organisation and networking. It is equally important how city administrations organise the delivery of this vision.1 WHO gives strategic leadership and technical support for reaching the goals of each five-year phase of Healthy Cities.1

Poverty and poor health are major challenges for cities.  Threats to good health for populations in cities include violence, social exclusion, pollution, lack of housing and unemployment.1 Efficient and well thought out city development and planning may be key to moving towards improved health equity for cities.1 Coherent policy and action is required by all government sectors and at various government levels. 1  Improvements to living standards will be based upon institutional changes and explicit political commitment.1 City governments have a vital role as advocates of health and especially providing tailored assistance to the most disadvantaged of groups.1

In the Regions for Health Network system, many nations within Europe have joined together to better address the social determinants of health and inequalities.1 As part of this health network program, within the countries participating, regions have been given defined political responsibilities.1 Involvement of stakeholders that are now working at sub-national levels has had positive results .1  For this progress to continue and expand more countries from Central and Eastern Europe may also be included in the future .1 It is however acknowledged that it can be challenging to design collaborative agreements which still work with the existing structures whilst catering to the diversity of newer arrangements.1 Successful approaches are likely those that undergo adaption and assessment before implementation.1 Evidence based approaches have been a goal for the members of the network system.1 Mutual commitment of WHO and sub-national bodies allows action to be based on a common agenda to promote health, reduce health inequities and strengthen regional governance in the area.1




  1. World Health Organisation (EU). Promoting health and reducing health inequities by addressing the social determinants of health [Internet]. World Health Organisation (EU); [cited 2014 Apr 5]. Available from:

Health Poverty Action promoting health for pastoralists in Ethiopia

Health Poverty Action works with some of the most marginalised and poorest communities in the world. Health Poverty Action works with Ethiopia to improve the health of pastoralists, particularly women and children.1

Ethiopia has the highest maternal mortality rates and lowest rates of health expenditure per individual in the world. 50 mothers die for every 100,000 live births and an estimate of nine in 10 births are not attended by a skilled health worker. Statistics for pastoralist groups are worse.1

Pastoralism is defined as the traditional way of life centering around livestock herding for food, materials and trade, which has been developed over many centuries as a sustainable livelihood in the world’s arid and semi-arid regions.5 Pastoralism is seen in all parts of Africa, where pastoral areas occupy 40% of Africa’s land area. It constitutes a central part of Africa’s heritage, history and culture. Pastoralists are nomadic, a group of people who move from one place to another to search for foods and water.5

There are approximately 12 to 15 million people from 29 different ethnic groups in pastoral regions of Ethiopia.1 There are poor equipments and insufficient health workers in the pastoral regions of Ethiopia. A large number of Health Extension Workers has been deployed by the Government of Ethiopia in the past few years to improve the accessibility and coverage of health services.1 However, the health coverage of the pastoralists remains low. Health Poverty Action provides on-the-job training to improve the quality of health services provided by the Health Extension Workers.1

Mobile clinics and community-constructed birthing huts can be constructed and implemented by NGOs such as Health Poverty Action.1 However, NGOs need to persuade state authorities to implement these interventions to tackle the lack of healthcare accessibility.1

Health Poverty Action works with pastoralist communities who live along the border of Ethiopia and Kenya, to increase healthcare accessibility in the Dollo Ado District in Ethiopia and Mandera West and Mandera Central districts in Kenya.2 This project is supported by European Union. The pastoralist communities are geographically isolated and are socially and economically marginalised.2 These communities are underrepresented and do not possess political authority in the government sectors.2  Health Poverty Action aims to train key health workers, provide more family planning options at local health facilities and raise health awareness for pastoralist communities.2

Health Poverty Action trains local organisations about health rights.2 Volunteers promote family planning and counselling.2 They also provide transport to healthcare services.2 Furthermore, they train traditional birth attendants in child care and counselling.2 Traditional birth attendants are provided with mobile phones to refer women to healthcare services. Health Poverty action strengthens local health networks so that women can gain quick access to healthcare services in case of pregnancy complications.2

The project in Bale Lowlands area of Ethiopia is funded by the European Commission. This project provides life-saving sexual and reproductive health services to pastoralist women in Bale lowlands.

Rainwater harvesting schemes are installed in healthcare facilities to improve quality of maternal and child health services and hygiene.3 Health staff is trained to provide life saving assistance to women during childbirth.3 Furthermore, Health Poverty Action increases awareness about HIV, harmful practices like female genital mutilation and encourages pastoralists to realise their right to health.3

The project to improve health services for South Omo and Dollo Ado pastoralists is funded by the Big Lottery Fund.4 Pastoralists are affected by drought and floods as they depend heavily on livestock. There are high maternal and child mortality rates as well as high levels of preventable diseases in the area.4

Health Poverty Action supports mobile voluntary counselling and testing outreach services for HIV. In addition, they support women’s health insurance groups to lend money for maternal child health emergencies.4 There are support groups for educating the communities of HIV and other sexually transmitted diseases.4 Tuberculosis and polio vaccination programs are provided for children.4

Health Poverty Action provides health advocacy principles and strategies to raise awareness via education campaigns. Healthcare services and vaccination programs are allocated for children to improve overall health of pastoralist communities.


  1. Health Poverty Action (UK). Strengthening marginalised communities along the Ethiopian and Kenyan border [Internet]. Health Poverty Action (UK); 2014 [cited 2014 Apr 3]. Available from:
  1. Health Poverty Action (UK). Strengthening marginalisedcommunities along the Ethiopian and Kenyan border [Internet]. Health Poverty Action (UK) [cited 2014 Apr 3]. Available from:
  1. Health Poverty Action (UK). Saving mothers’lives in the Bale lowlands [Internet]. Health Poverty Action (UK) [cited 2014 Apr 3]. Available from:
  1. Health Poverty Action (UK). Improving health services for South Omo and Dollo Ado pastoralists [Internet]. Health Poverty Action (UK) [cited 2014 Apr 3]. Available from:
  1. International Human Rights. Pastoralism and the discrimination of sustainable livelihoods [Internet]. Australian International Human Rights; 2013 [cited 2014 Apr 3]. Available from:

Global strategies: The Millennium Development goals

Millennium Development goals are a set of targets implemented by the world’s nations to fight against global poverty and inequality by 2015. There are eight achievable commitments to improve the wellbeing of the world’s poorest people.

The first goal is to eradicate extreme hunger and poverty.

  • To reduce the proportion of people whose income is less than $1 a day by ½ between 1990 and 2015.1
  • To reduce the proportion of people who suffer from hunger between 1990 and 2015.1
  • To provide job opportunities and employment for all.1

The second goal is to achieve universal primary education for children everywhere, regardless of gender, by 2015.1

The third goal is to promote gender equality and empower women by eliminating gender disparity in all levels of education by 2015.1

The fourth goal is reducing the under-five child mortality by 2/3 between 1990 and 2015.1

The fifth goal is improving maternal health.

  • The maternal mortality ratio is reduced by ¾ between 1990 and 2015.1
  • To achieve universal access to reproductive health.1

The sixth goal is to combat HIV/AIDS, malaria and other diseases

  • To stop and reverse the spread of HIV/AIDS by 2015.1
  • Achieving universal access to HIV/AIDS treatment by 2010.1
  • Stop and reverse the incidence of malaria and other major diseases by 2015.1

The seventh goal is to ensure environmental sustainability.

  • Halve the proportion of people without sustainable access to safe drinking water and basic sanitation by 2015.1
  • The integration of principles of sustainable development into country policies and programs and reversing the loss of environmental resources.1

The final goal is developing a global partnership for development by addressing the special needs of least developed countries.1 This goal allows development of open and non-discriminatory trading and financial system. Cooperation with private sectors to obtain  benefits of new and latest technologies, such as gaining information and communications. Last but not least, to cooperate with pharmaceutical companies to provide access to affordable essential drugs.

Challenges for the future

MDGs have achieved significant progress since 1990 where 700 million fewer people live in extreme poverty.  5.1 million more children, aged 5 years old or younger, survive each year since 1990.1

Despite these achievements, 1 billion people continue to suffer in poverty. Though more children are able to attend school now, there will still be a skewed distribution of access to early learning and secondary education globally.1 287,000 women who are mostly from those populations who are living in poverty still die from preventable and treatable pregnancy and birth complications.1 A significant number of children who die in their first day or month of life remains, with 6.9 million children under-five dying every year.1

These statistics show how different quality in life is in less developed nations compared to developed. Whilst we enjoy living in privileged countries, many communities and individuals continue to suffer from environments which they are essentially trapped in. Targeting social injustice in many nations will likely amplify the effect of the aid that is delivered by WHO under these goals.

It is clear that strategies that involve clear targets and timelines are important for giving us something to work towards. By providing a framework that is easy to understand and promote, WHO is allowing us to becoming better informed.



  1. Australian Government Department of Foreign Affairs and Trade (AU). Millennium Development Goals [Internet]. Australian Government Department of Foreign Affairs and Trade (AU); 2013 [updated 2013 Nov 21; cited 2014 Apr 1]. Available from: