SOUTH ASIAN DIALOGUE ON POVERTY AND HEALTH HELD IN BANGALORE 15TH - 18TH NOVEMBER 1999
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RF_COM_H_70_C_PART_B_SUDHA
Poverty And Health: Universal Abuse Of Human Rights
sunil kaul'
Summary: The links between poverty and health have been well documented and proved. The first two articles of
the Universal Declaration of Human Rights continue to be abused universally as the poor live a life bereft of
human dignity and suffer from ill-health and early death in all countries. If the world is serious about going
beyond the platitudes of declaration of human rights and see them as a reality, the author argues that there needs to
be a universal acceptance of a definition of humans without discriminations of any kind, including on the basis of
place of birth. Universalisation of Human Rights needs to be seen as priority and that it can be possible through a
small amendment in the UDHR and a more democratic UN.
The Universal Declaration of Human Rights (UDHR) in 1948 can be said to be a landmark in the fight
for human rights. Articles 1 and 21 set out the applicability and basis of the rights given in the
subsequent articles. These state that all people are bom equal in dignity and rights and that these rights
are guaranteed to everyone".
The success of the efforts of the Human Rights agenda cannot be denied. Despite the continuing
differences of opinion against the universalisation of standards, esp. from the Asian countries3, the
concept of universality has been ratified by the successes seen in the drafting of regional charters of
Human Rights in different forms in Asia, Africa, Europe and America. While the Africans take the
concept of cultural relativism, the Asians emphasise the State and the other two only deal with civil and
political rights.4 Since societal development has never been the same anywhere, and human rights
contents are rooted in certain social facts of particular societies, human rights are both conceived and
observed differently, and universality the world over is at least a myth for the present5.
Poverty, Human Rights and Public Health
One fourth of the world’s population lives in conditions of severe poverty6 without basic necessities of
food, clothing, shelter, and hygiene and sanitation. There needs little argument to prove that conditions
of abject poverty in developing and underdeveloped countries often does not support conditions of
human dignity. The frustration of living insecure lives, facing hunger and disease as a habit often drives
people to a life of crime, prostitution, selling of children and suicide.
Infant Mortality Rates are considered to be the best indicator of a community’s health status.7 That
deaths due to infantile diseases - and also diseases like tuberculosis — were linked to poverty and living
conditions was proved by the classical work of McKeown.8 In recognition of its links with the deaths of
many people, an international code of diagnosis Z59.5 was provided to Extreme Poverty in 1993 to be
available to physicians as a cause of death.’ It isn’t surprising that most of the world’s people who die
of poverty linked diseases e.g., diseases due to lack of nutrition, hygiene or sanitation live in the
developing and underdeveloped countries.10
Besides living conditions, respect for human dignity has also been considered to be an essential element
of health and well-being for all people." That poor and marginalised people have had to suffer more
than their fair share of indignity of not only infectious diseases, but also of public health measures to
prevent or treat them as has been seen in the case of smallpox, cholera, venereal diseases, AIDS12, and
TB13 and this is not a new phenomenon in public health history. Even to date, the poor are considered to
be increasing their misery by breeding too much and subjected to coercive reproductive
porgrammes1'’,15 by their governments. Other links between public health and human rights have been
comprehensively demonstrated by Jonathan Mann where he states that human rights and human dignity
are engaged to such an extent that physicians are compelled to go beyond the usual limited boundaries
of medical care.16
Imperialism, Neoliberalism and Human Rights
;
Ninety percent of the world’s poor live in developing and underdeveloped countries,17 most of whidh
were under imperialist rules till a few decades ago in Asia and Africa. The industrialisation of Europe
‘ 144 Akash Darshan, 12 Mayur Vihar-I Delhi 110091 e-mail: sunilkaul@mantraonline.com
and America helped exploit the natural reserves of pre-industrial societies of the other continents, and
delayed the movements for democracy and liberalisation that were sweeping their own continents.18
The governments of these countries are still struggling to come to terms with providing their
populations a life of basic human dignity and fundamental human rights. Although most have signed
their regional charters for human rights, they are more serious about civil and political rights than about
dealing with poverty.
Although ‘neoliberalism’ has substituted for imperialism and the ‘oligarchy’ in the discourse of the left,
it cannot be said that liberalisation directly causes human rights violations. To the contrary, most
international investors prefer to work in liberal democracies and promote them. ‘Market forces,
however, do not just favour the rule of the law, but also bring about the exclusion and marginalisation
of all those who do not have the necessary skills to adapt to the market economy’. Economic Reform in
many countries has been centred around the International Monetary Fund and not just social inequity,
but the state provisions for sectors like education, health and social security for the traditional poor
and the middle class have deteriorated under the structural adjustments. These effects are likely to
cause abrogation of human rights.19 The disintegration of public order, criminality and human rights
violations because of a sudden return to poverty for a large part of population in South East Asia in last
year’s economic collapse can be seen in the same light.
Responsibility of Human Rights
Because of such effects of the recent history of imperialism, of marketisation of economies and other
effects beyond their immediate control, many governments have been hesitating in accepting universal
standards of human rights because the Preamble of the UDHR exhorts member states to provide the
rights and liberties; consequently it is they who will be held responsible for any violation.
But is it fair that nation-states should be held accountable for all lapses in human rights? For crimes like
those of ethnic cleansing with official complicity, as in the case of Rwanda and Yugoslavia20, most
seem to agree that the two tribunals that looked into the crimes cannot be faulted for their indictments
of governments and their officials. Even then, there is a concern amongst smaller and poorer nations
that their human rights are more likely to be highlighted and punished by the Americans and Europeans,
who are seen as pushing the Human Rights agenda, in comparison to the violations of US - and many
of its world-wide authoritarian allies, like China — which itself has had a rather vacillating and arbitrary'
concern for human rights21.
External factors
For human rights violations that occur on account of nation states functioning in a global village
scenario with a history and geography allocated to them without a democratic choice, can the
distinction be clear as to who ought to be blamed?
Firstly, the tragedies of Rwanda cannot be wished away by a simple indictment and punishment of
officials. Maurice King would argue that the Rwandan tragedy would be followed by many more and
should be seen more as a public health crisis of decreasing mortality rates amongst demographic
populations who are trapped in a fixed resource scenario and suffer from a phenomenon of
‘demographic entrapment’.22
Secondly, although nations - states are expected to deliver human rights as a legacy of the Westphalian
order of Europe developed since the 17lh century,23 the sovereignty of states over nations has not been
so easy. The geography was allotted to states in a hurry after the Second World War by an arbitrary
drawing of lines - often ruler-straight, as any map of Africa will display - by cartographers cutting
nations of people into several states, e.g., the Kurds in Turkey, Iraq, Iran, Syria, Armenia and
Azerbaijan; the Tutsis and Hutus, both in Rwanda and Burundi; Tamils in India and Sri Lanka, etc.
Also, nations held together by a brutal and undemocratic colonial power were handed over to the
dominant nation-state at the time of departure by the Western powers. The new governments are
expected to hold on to the pieces of cake by the processes of democracy, which is not easy if
democracy can be equated to be the dictatorship of the majority. With the rights of indigenous people
being recognised and supported by the international community, democratic governments coming to
power by the will of the majority are unable to grant secession rights to the minorities. For instance,
India can be seen to face endless problems in balancing human rights concerns voiced from within and
outside the country, and the majority’s aspirations of not losing any more land in Nagaland and
Kashmir.
Thirdly, armed conflicts are increasing instead of decreasing after the cold war period and numbered
more than fifty around the world in 1997. They not only cause rampant human rights abuses, and
prolonged exposures of poverty,'4 but also expose the role of many nations external to the conflict who
are worsening the crisis by their help in terms of money, weapons and training, or sometimes, even
humanitarian aid.
Suspicions about the West
In such situations, is it right for the UDHR'to put the onus of preservation of human rights only on the
governments of nation-states? The concern of smaller nation states that they will be held accountable
for violating the UDHR for problems not entirely of their own making is genuine. Also proven
repeatedly in the recent past is the fact that European nations and the US, sitting in a UN Security
Council dominated by the victors of the second world war use their political and economic clout to
initiate military' action not by virtue of principle, but by matters of expediency. While China went scotfree despite its Tiananmen, Iraq trying to redraw its boundaries to precolonial times after being hit
economically by Kuwaiti oil policy was severely punished. Many dictatorships were installed and
supported by the West, e.g., Indonesia and South Korea despite their poor human rights records as long
as they professed a market economy. So is the case of many other dictatorships in Africa which
wouldn’t survive a day without the support of Western countries who benefit from the large scale
exploitation of their natural resources.
It is this arbitrariness that breeds cynicism about the intentions of the UN, the platform that gave birth
to the UDHR. The human rights agenda can be universally adopted, as the spirit of human rights is
something that all religions, cultures and nations are ready to concede and have believed in one form or
the other25.
Discrimination in the West
The West itself has one tenth of the World’s poor and the number of people living in poverty has
drastically increased in the last few decades, and this distribution of poverty is not random26. Although
the West can boast of most of the world’s richest 225 people whose wealth equals what 47% of the
world’s population can earn in a year,27 it refuses to share more of its wealth, most of which was
developed from the past or continued exploitation of the rest of the world. Yet, it denies human rights
to anyone except its own citizens. Instead of leading the world to a place without any discrimination, as
it would have us believe with its human rights concerns, its discrimination on the basis of place of birth
has become worse if the curbs on immigration and treatment of immigrants is an indicator.28
The pace of globalisation in terms of ‘economic, political and cultural interdependence on the other
hand, has undermined the sovereignty as well as the autonomy of nation-states.29 When resources get
limited because nations are trapped within geographical confines of ecosystems unable to sustain the
population without exploitation of natural resources, the continued departure from the pre-colonial
right to free travel will have a worsening effect on human existence. The consequences of a failed
reform of economic agenda (forced once again by a Western market system); the free trade agenda that
has to be signed to survive in the global world in the form of GATT; newer public health problems that
have their roots in faster travel30 and communication; environmental degradation as a consequence of
industrialised economic systems, e.g., AIDS - all point to a responsibility of Human Rights violations
that cannot be placed only on the governments of nation states. The Universal Human Rights Agenda,
though a legitimate one, becomes much more contentious to implement if carried out in the present
paradigm of a world that shrugs off responsibility of the indignity that is heaped on human beings
existing beyond its land boundaries.
The way forward
The goals of the UDHR are just and need universalisation. But before the distant ‘universalisation,’ let
us try to achieve ‘globalisation’ first. Human beings globally need to have the basic needs for survival
without severe poverty to enjoy lives befitting human dignity- of global citizens. Globalisation of the
world is a reality and should appear as a boon rather than a curse for humanity. The need of the hour is
to ensure that all humans enjoy the fruit of globalisation and of the scientific and technological
advances made without discrimination. For this, the basic human right of equality of all human beings
on the globe must be protected by global agencies under democratic controls to gain the confidence and
co-operation of the majority of the world.
Global citizens
We have to recognise that ‘the time of absolute sovereignty, has passed’,31 and there is a need for
countries to recognise tire need for co-operation and to press for the rights of human beings as are
enshrined in the spirit and the first two articles of the UDHR.
Universal Human Rights will not be possible unless there is an ‘agreement about the ontological
foundations of those values (of human rights) and about the limits to the applicability of the
principles”2. Liberalisation is here to stay and the freedom to travel across geographical boundaries that
has been with us since the birth of civilisation has to be recognised. Article 13 of the UDHR needs to be
amended consequently. Not just humans, all living beings have moved from a resource poor area to
resource rich area until the previous ecosystem regenerated or was found conducive for living once
again. The right to travel without visas and passports is in line with the logic of liberalism3’ and with
Article 25 of the UDHR which grants the right to a person ‘to a standard of living adequate for the
health and well-being of himself and his family, including food, clothing, housing and medical care
5 34
Modern civilisations and nation-state concepts have abrogated this right to move. The principles of
Universal Human Rights must be in the spirit of liberalised thought and ought to recreate this ancient
right rather than limit it under Article 13. The sooner this anomaly is corrected, the sooner will the just
and humane goals of Universal human Rights be achieved. The contradictions between the sections of
the UDHR keeping in mind the history, geography and economy of the modern world, need to be
removed at the earliest.
Such a move to create ‘global citizens’ would not only go a long way in removing geo-social disparities
of poverty' and geographical entrapments, it would also prevent the cross border environmental damage
and exploitation, because the effects would drive home the point much faster. It would, in one stroke,
not just make the bases of human rights laid out in Articles 1 and 2 more real and meaningful, but
would also help the cause of the environmentalists and have a tremendous effect on the
determinants of health by redistributing resources and bringing equity.
Global equality
To safeguard this right however, there will be a need for a commitment at the level of the UN and that
would not be possible unless the UN gets democratised. The constitution of the monitoring body of the
UN that has different allocations of power to different nations and does not treat all its member states
as equal, itself is violative of the UDHR. There is an urgent need to democratise and remove the
permanent membership clause of the Security Council. Membership could be based on a rotating
pattern, and in the spirit of equity as opposed to equality, there could be more seats allocated to the
resource poor nations than to the resource rich. The principle of equality can be brought back once the
universal basic needs of people of life with food, shelter and clothing that provide human dignity and
determine health are achieved. Its job would be to monitor the human rights of people, including the
right to a life with dignity and without poverty in all parts of the globe.
Since signatories of today have already pledged to the principles of equal human rights, it should follow
that the UN’s body needed to monitor human rights would be funded by members based on their per
capita GDP. Although this has always been the principle agreed even for development aid, most of the
richer nations have consistently defaulted on their aid commitments35 both to the poorer countries and
to the UN itself and often used it for political leverage.
Global military
Last, but not the least, the control of Security Forces must pass on to the UN in a globalised world that
has a global, universal definition of human being. It would be necessary to ensure that people are not
prevented from moving out from one ecosystem to another. A democratic framework of the UN which
sanctions the use of force in defence of human rights violations would be a necessary prerequisite of
this.
Conclusion
Human beings are bom equal and are equal in dignity and rights as per the UDHR signed by most
countries of the world. However, the UN system that needs to monitor this, and the West which has
been in the forefront of the human rights agenda, have themselves been violative of the spirit of the
UDHR. The basic rights of peoples to move from resource depleted ecosystems to resource rich areas
have been denied by the UDHR in its present form and the world ordpr of today. This anomaly of the
UDHR, whereby its Article 13 prevents Article 25 from being meaningful and allows discrimination on
the basis of place of birth - that is protected under Article 1 and 2, must be removed at the earliest.
Universal Human Rights must see a right not as what someone gives you, but as what no one can take
away from you36. In its present shape, UDHR tries to restrict this right rather than to promote it. A
democratic UN to monitor an amended UDHR is the best way forward if we want the spirit of
Universal Human Rights from becoming a reality in the near future.
' General Assembly Resolution 217A(III), UN document A/810 at 71(1948), United Nations, New York.
http://www.un.org and http:/www.um.edu/humanrts/
2 The Writing Group for the Consortium for Health and Human Rights, Health and Human Rights: A Call to
Action on the 5011' Anniversary of the Universal Declaration of Human Rights. JAMA, Vol. 280, No. 5:462
3 Boyle K, Stock Taking on Human Rights: the World Conference on Human Rights, Vienna 1993 in Beetham D
(ed.), Politics and Human Rights, Blackwell, Oxford. 1995:87-88.
4 Lindholt Z, Questioning the Universality of Human Rights. Dartmouth, England 1997:8
3 Ibid: 24-27.
6 UNDP, Human Development Report, 1998.
’ Park K, Textbook of Preventive and Social Medicine, Bhanot, India, 1994:20.
’ McKeown T, The Origins ofHuman Disease. Blackwell, London. 1988.
’ WHO, World Health Report, 1994. Geneva.: 1.
10 WHO, World Health Report, 1998. Geneva.
" Ref. 2 above.:462
12 Porter R and Porter D, AIDS, Law, Liberty and Public Health in Byrne P, Health Rights and Resources, King
Edward’s Memorial Fund, London.:76-99
I
13 Porter J and Ogden J, Public Health, Ethics and Tuberculosis, Ind. J. Tub 1999, 46, 3-5.
14 Thomas JW, and Grindle MS, Political Leadership and Policy Characteristics in Population Policy Reform in
Finkle J and McIntosh C (eds.) The New Politics of
Population: Conflict and Consensus in Family Planning. NY: Population Council :54.
13 Human Rights Watch, Death by Default: A Policy of Fatal Neglect in China's State Orphanages. New York:
Human Rights Watch 1996.
16 Mann J, Medicine and Public Health, Ethics and Human Rights, Hastings Center Report. May-June 1997: 6-13.
17 UNDP, Human Development Report, 1998.
" Van Bulert V, Raja Ram Mohun Roy's Thought and its Relevance for Human Rights in Na’im A et al(eds.),
Human Rights and Religious Values: An Uneasy Relationship, WmEerdmans, Amsterdam: 97.
” Panizza F, Human Rights in the Processes of Transition and Consolidation of Democracy in Latin America in
Beetham D (ed.), Politics and Human Rights, Blackwell, Oxford. 1995: 168-188.
20 Lindholt Z, Questioning the Universality of Human Rights. Dartmouth, England 1997: 258.
21 Forsythe D P, Human Rights and US Foreign Policy: Two Levels, Two Worlds, in Beetham D (ed.), Politics
and Human Rights, Blackwell, Oxford. 1995: 111-130.
22 King MH and Elliott CM, The diseases ofgods: some newer threats to health, Oxford Textbook of Medicine,
Oxford, 1996: 37.
23 Rosas A, State Sovereignty and Human Rights: towards a Global Constitutional Project in Beetham D (ed.),
Politics and Human Rights, Blackwell, Oxford. 1995:64-66.
24 The Writing Group for the Consortium for Health and Human Rights, Health and Human Rights: A Call to
Action on the 30jh Anniversary of the Universal Declaration of Human Rights. JAMA, Vol. 280, No. 5:463.
“ Workshop Statement Free University Amsterdam, Human Rights and Religious Anthropologies, in Na’im A et
al(eds.), Human Rights and Religious Values: An Uneasy Relationship, WmEerdmans, Amsterdam: 267-268.
26 Waters T, Chesson's choice. New Internationalist. March 1999:16
27 The Poverty Quiz, New Internationalist. March 1999: 11 & 30.
2S Cornelius WA, Martin PL, and Hollifield J, Controlling Immigration: A Global Perspective, Stanford Univ
Press, Calif. 1992: 11.
” Held David, cited in Dandekar C, Nationalisnm and Violence : 37.
30 WHO, Good health promotes development - Development promotes health.
Http://www.who.ch/aboutwho/good.htm : 05/23/98
51 Ghali, Boutros B, An Agenda for Peace, Secretary General’s Report 1992. http://www.un.org/publications
32 Castillo M, cited in Lassonde, L, Coping with Population Challenges, Earthscan, London 1997: 154.
33 Wallerstein I, The insurmountable Contradictions of Liberalism: Human Rights and the Rights of the Peoples
in the Geoculure of the Modern World-System. in Mudimbe VY (ed.), Nations, Identities, and Cultures, Duke
Univ Press, US, 1997:129.
34 General Assembly Resolution 217A(III), UN document A/810 at 71(1948), United Nations, New York.
http://www.un.org and http:/www.um.edu/humanrts/
33 unicef, The Progress ofNations, 1998, UN, New York, 1998: 33.
36 Clark Ramsay, US Attorney General in New York Times, 2nd Oct 1977 in Microsoft Bookshelf Columbia
Dictionary of Quotations 1998, US on CD-ROM.
POVERTY IN INDIA: OPTIONS FOR ALLEVIATION
The Face of Poverty in India *
In half century since Independence in 1947, India has made notable
social and economic achievements.
•
Eradication of famine, reduction in population growth rate and
creation of a large reservoir of scientific and technical manpower.
•
Reduction of poverty since the 1970s.
•
When policies have increased growth fate , particularly agricultural
growth rate, and improved human development, poverty has fallen
faster.
1950
45%
164 million
1993-1994
36%
320 million (76% live in rural areas)
♦ Being poor in India means lacking good health and skills to make the most
of the economic opportunities growth can open.
♦ Better health status of the poor in Kerala is largely explained by its better
education, water and sanitation and basic infrastructure services.
♦ Being a poor pregnant women means risking death. India’s MMR at
437/100,000 means 1 in every 4 maternal deaths world wide.
♦ Differences in reaching the poor and reducing poverty reflect more than
natural advantages or disadvantages. They partly reflect policy
interventions to improve the health and education of the poor and,
consequently, their opportunities to gain a share of economic progress.
♦
Having foregone such investments, Bihar has lowest literacy and sixth
highest MMR.
Research for WDR 2000
* Nores
prom
lam@>a
India - Health Poverty Facts Sheet 1992-1993
Ratio
Lowest 20%
Highest 20%
IMR
94.7
46.3
>5 MR
137.7
61.3
2.24
Percent Stunted
56.7
38.9
1 45
Percent underweight
59.3
40.3
1.47
TFR
4.5
3.4
1.32
HNP Status
.
2.05
HNP Services show corresponding variations.
Position is aggravated when Urban Rural data is desegregated
Achievements and Challenges in Reducing Poverty in India
Where does India stand?
Year
% below the poverty line
1951
50
Total (millions) below the
poverty line
164
1993-94
^^312
36.7
Rural
30.5
Urban
240.5
Rural
(77% of poor
Indians)
71.5
Urban
Poverty in India is responsive to its economic growth:
Annual per capita income grew by 1.7%
1951-75
Annual decline in poverty by 0.9%
Annual per capital income grew by 2.5%
Mid 70s - late 80s
Annual decline in poverty by 2.4%
The above pattern holds for both rural and urban poverty.
Indicators that measure the depth (poverty gap) and severity (squared poverty
gap) of poverty suggest the process of decline in poverty included those whose
consumption levels were far below the poverty line.
Source: Research done for WDR 2000
Responsiveness of poverty to economic growth implies that through rapid
growth India will be able to reduce poverty and generate the resources to invest in
health and education of its people, who, in turn, will sustain this growth.
Nonetheless, because of rapid population growth rate, the absolute number
of poor has increased by 190% between 1951 and 1993-94.
While the decline in poverty has been sizeable - from 56% in parly 1970s to
35% in 1993-94, it has been modest compared to Indonesia, whose poverty dropped
from 58% in 1970 to 8% in 1993 - an annual decline of nearly 10%.
As of 1993-94, India's poverty is predominantly rural, even though rural
poverty declined faster than urban poverty: decline in national poverty has been
mostly driven by the decline in rural poverty - not surprising given that 74% of the
population lies in rural areas.
The above findings, based on 40 years of nationally representative household
surveys, are reinforced by a host of multidisciplinary village studies.
How do the poor fare regarding other indicators of well-being
Year-1991
Literacy % (aged 7 and above) of total population
India
52
Sri Lanka
89
China
78
Thailand
94
Indonesia
84
Life expectancy (in years)
India
59
Sri Lanka
72
China
69
Thailand
69
(30 in 1947)
Infant Mortality Rate (per 1000 live births)
India
79
China
31
Thailand
26
Sri Lanka
18
(146 in the 1950)
Malnutrition
Notwithstanding significant improvements in food availability and its
distribution, India’s rates of malnutrition among children and women are
among the highest in the world.
Analyses of cross-country patterns indicate that the most important
factor accounting for differences in social indicators is India’s per capita
income.
Who are the Poor?
The following are closely associated with poverty:
Gender
Literacy (45% in households without anyone literate)
Land ownership (52% for land less as a whole)
Employment status (68% - land less wage earners)
Caste (51% - including Tribes) (Population 206 million)
The figures in brackets against the above indicate the incidence
of poverty revealed by a recent survey of rural households.
Disparities in Poverty in India
Different States in India have progressed at different paces and,
even within States, different regions have achieved marked varied
results.
Inequalities that persist across gender, caste and ethnic groups
are even more noticeable. Social indicators for women-literacy, for
example, are markedly lower than for men. The level of scheduled
castes and tribes, in both social and economic achievements, are still
below the national average.
The range of poverty reduction among the States is so wide that
Kerala’s progress in lowering the headcount index of poverty (2.4% per
year, on an average between 1957-58 and 1993-94) is more than 120
times that of Bihar and more than 4 times that of Rajasthan.
These differences reflect more than natural advantages or
disadvantages. They mirror, instead, conscious decisions on investing
in the poor, especially in improving their health and education and,
consequently, their opportunities to participate in economic progress.
As a result of these decisions, Bihar - the poorest amongst the
17 largest States which account for over 90% of the population, has the
5th lowest level of male life expectancy, the low level of male literacy,
the 2nd lowest level of female literacy and the 7lh highest level of infant
mortality. Kerala, by contrast, has the lowest infant mortality rate and
the 2nd highest rates of male and female literacy.
Reducing Poverty : What matters most?
Since Independence in 1947, Governments have relied on two
approaches to reducing poverty.
First, the effects of aggregate rural growth would spread to all groups in
society such that poverty reduction is achieved side by side with increases in
economic growth.
Second, specific anti-poverty programmes are required.
The slow reduction in poverty through the 1950s and 1960s reinforced
skepticism regarding the strength of any trickle-down effect.
However, since the mid 1970s, the faster poverty decline alongside a
higher rate of economic growth, both in India and the developing world, has
led to a greater appreciation of the contribution of growth to lasting poverty
reduction and, equally importantly, reinforced the need for investing more in
human resources development, since these investments not only contribute
to faster long term growth, they also increase the capacity of the poor to
benefit from it.
Accordingly, government’s strategy over the recent past increased its
emphasis on providing the conditions for accelerated and sustained labour-
intensive growth, while expanding investment in human capital development.
Puzzles
Failure of India's primary health centers to deliver the care to reduce
infant mortality.
Low utilization of public health facilities, despite poverty.
Increasing dependence on private (all types) health care: rising private
expenditure on health care => deepening poverty.
Public Policy =>Poverty Reduction
Impact of public expenditure on health outcomes, especially on the
poor, appear to differ greatly from one intervention to another and place to
place.
Four priority areas for increasing the impact of public spending on the
health of the poor, and indeed the economy in general, are:
1.
The gains from public health spending combating
communicable diseases, particularly for the poor would be
substantial.
2.
Improving access to safe water, sanitation and vaccinations
would help reduce IMR and child mortality, and thus lower
fertility and improve maternal health.
3.
Health education - basic hygiene, value of better nutrition,
preventive health care, campaigns against tobacco use, HIV-
AIDS/STDs prevention etc are important behavioural changes
needed for cost effective health development.
4.
The poor must often meet the financial burden of medical
emergencies through debt, distress sale of real assets, and
reduction in consumption of food etc. There is merit in
subsidizing hospital treatment. (The benefit of subsidizing
hospital treatment of the poor is in the range of 40 to 70% of the
cost of providing the service to the lowest 40% of the population)
OPTIONS
How to meet the health need of the poor
Choices before the government
•
Suppress private sector, particularly unqualified providers: How to replace
their services?
Regulate
Self-regulate
•
Continue as a provider of different levels of health services.
•
To do so better - how to finance and manage quality?
What areas government should concentrate on
Empower consumers through education
Provide insurance against catastrophic illness.
Strengthen local planning, management and accountability of public
health services.
Choices for NGO actions
■
Continue business as usual-effective work in small populations/areas.
■
How majority of people would be addressed?
New modalities in financing, organization and community participation
Go to scale
Raise public awareness' and increase demand
Choices for collaboration
> Support by government to private sector, e.g. training and supply of
anticeptics, drugs and contraceptives, etc.
> Government grants for primary care to NGOs
> Develop provider networks serving the poor
Choices for external agencies
•
Funding of better States/NGOs
•
Policy advice
•
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PEOPLE’S CAMPAIGN FOR DECENTRALISED PLANNING
AND
THE HEALTH SECTOR IN KERALA
Dr. B. Ekbal
In spite of the economic backwardness, Kerala has made remarkable achievements in
health almost comparable to that of even developed countries. The widely accepted
health indicators like crude death rate, infant mortality rate, and life expectancy
evidence this. (Table 1)
Most analysts have seen Kerala’s achievements in health as something of an enigma.
Kerala achieved the health status as par with that of USA spending roughly 10 US $
per capita per year while US spends about 3500 S per capita per year on health care.
The GDP of Kerala is even less than that of the National average. Kerala’s
achievement in health in spite of its economic backwardness and very low health
spending has prompted many analysts to talk about a unique “Kerala Model of
Health,” worth emulating by other developing parts of the world
KERALA MODEL OF HEALTH
There are many socio-economic conditions unique to Kerala, which have been
postulated to make this health model possible. Kerala has a highly literate population
compared to other Indian states. This especially the high female literacy, has to be
given due credit when we look for explanatory factors. All over, the world indices
such as infant mortality have shown an inverse relationship with female literacy.
It is also to be noted that Kerala has nurtured a political climate wherein the rights of
the poor and the under privileged have been upheld and fought for. This was the result
of a fairly long period of struggle for social reforms exphasising dignity of people
who were considered socially ‘inferior’ which later found expression in seculardemocratic movements culminating in nationalist and socialist movements. One
common thrust of all such movements was on education and organisation of the
downtrodden people. Hence, as has been pointed by many social scientists there is a
remarkable reduction in the rate of exploitation of the underprivileged in Kerala
compared to other Indian states.
The agrarian reforms that were implemented in the late 1950s ended the feudal
relationship in agriculture and giving land to the tillers. This improved the social
living conditions of the landless poor in the rural areas. This might have contributed to
the alleviation of poverty among the agricultural laborers leading to the improvement
of their health status.
The public distribution system of food through fair-priced rations shops distributed
throughout Kerala assures minimum food materials at relatively cheap cost to the
people. This has assured certain amount of nutritional status to the poor, warding of
poverty related diseases.
Apart from the socio-economic factors outlined above the universally available public
health, system in Kerala has also contributed to the high health status of the people.
Kerala has a three-tier system of health care, the Primary Health Centres (PHC) and
the Community Health Centres (CHC), Taluk and District Hospitals and the Medical
Colleges evenly distributed both in the urban and the rural areas. Apart from Modern
Medicine. Ayurveda, Homeopathy, and other alternative systems are also very
popular in Kerala.
However, the widely acclaimed Kerala Model of Health has started showing a
number of disturbing trends recently.
KERALA HEALTH FROM SUCCESS TO CRISIS
Although the mortality is low, the morbidity (those suffering from diseases) is high in
Kerala compared to other Indian states. Though there is a data gap in this regard the
NSS (1974) and KSSP (1987) studies confirmed these observations (Table 2). Hence
the Kerala situation was described as ‘Low Mortality High Morbidity Syndrome”
(Panicker and Soman 1985). It can be argued that when the expectancy of life
increases there can be a corresponding increase in morbidity in terms of the high
incidence of diseases like Cancer, Heart diseases etc. that affect old age people more.
However, here also the Kerala situation is peculiar in that the infectious diseases like
diarrhoea, hepatitis, tuberculosis etc are still prevalent in Kerala. Moreover, many
epidemics that were supposed to have been eliminated from Kerala like Malaria are
definitely staging a come back. In addition, diseases like Japanese Encephalitis that
was sporadic in Kerala has appeared in many parts of the state as epidemic apart from
the appearance of the modem scourge like AIDS.
Another disturbing trend is that the Public Health System is getting alienated from the
people and only 30% of the people even from the lower income group seek medical
help from the Government hospitals (Table 3). This is because of the fall in the
quality of services at the Government hospitals. Lack of political commitment,
bureaucratic inefficiency, corruption at various levels, lack of proper planning etc has
contributed to this sorry state of affairs.
This environment of the perceived inefficiency of the Government medical facilities is
one of the factors that provided the impetus for the growth of the private medical care
set up in the state. The social milieu of the state is changing and features of a
consumer society are visible in all occupations. This has led to the commercialisation
and the commodification of health care. Health is no more seen as a right but as a
commodity to be purchased by money. The huge remittance of foreign exchange from
gulf countries even to the low and middle-income group houses further reinforced this
attitude. All these tendencies are leading to a virtual uncontrolled growth of the
private medical care facilities in the state.
A comparison of the infrastructure and health manpower development in the private
and public sectors confirms the supremacy of the private sector in the state. The
number of beds in the government institutions grew from around 36000 to 38000 in
the 10-year period from 1986 to 1996, whereas in the same period, beds in private
institutions grew from 49000 to 675000. This amounts to nearly 40% growth in the
private sector beds in a period of 10 years as against nearly 5.5% in the Government
3
sector. In the case of doctors about 5000 doctors work in the government sector
whereas double the number work in the private sector (Table 4). More significantly,
private sector has far outpaced the government facilities in the provision of
sophisticated modalities of diagnosis and therapy, such as CT Scans, MRI Scans,
Endoscopy Units etc. Simultaneously, public sector itself is being subjected to internal
privatization. Because of the irregular supply of medicines and other materials
patients seeking medical care from the government hospitals are forced to buy them
from outside. Also the laboratory facilities are quite inadequate in the government
hospitals and patients have to depend upon the private labs for getting investigations
done in time.
The privatisation of medical care is leading to over medicalisation and escalation of
the health care cost. The net result is the marginalisation of the poor and it is roughly
estimated that at least 30% of the people in the state are denied health care or find it
extremely difficult to meet the growing health expenditure.
The changing health scenario in Kerala has provoked analysts like the present author
to comment that the Kerala Model of Health Care is slowly drifting towards an
American Model of Health Care. The hallmarks of Kerala Model were low cost of
health care and its universal accessibility and availability even to the poorer sections
of society. This may be changing to the American Model where in spite of the
technological supremacy 40 million people are denied health care because of
privatisation and the escalation of the health care cost.
In short the important aspects of the present health scenario in Kerala are:
1. The simultaneous presence of the diseases of poverty and the diseases of affluence
or life style diseases.
2. The decay of the public health system.
3. The uncontrolled growth of the private sector.
4. Escalation of health care cost.
5. Marginalisation of poor.
TOWARDS A PEOPLE’S HEALTH POLICY
Toning up of the health care system in the state and making it capable of taking on the
burden of provision of equitable, efficient and good quality health care needs
concerted actions from the political parties, social movements and the professional
organisations. Taking into consideration the specific problems of the Kerala health
scenario a People’s Health Policy for Kerala should be formulated. Reinstating the
primacy of the government health services, with its emphasis on primary health care
should form the basis of the health policy for Kerala. There should be some amount of
social control and auditing of the private sector.
DECENTRALISATION AND COMMUNITY INVOLVEMENT IN HEALTH
These objectives can be realised only through an administrative and financial
decentralisation of the health services department, while ensuring community
involvement in formulating and implementing health care programs and reforms. The
Panchath Raj now provides the possibility for the people to demand the resources to
operate a health service in which the people themselves will play the dominant role
and of which they will be the chief beneficiaries. All infrastructure, health manpower
development, training, distribution, and production of drugs and equipment must
conform to achieve this, and not in reverse as is at present. Only thus can a cost
effective, human and accountable health sendee be provided that is funded and
operated by the local bodies with the technical assistance of the health professionals.
This system involves the entire community and especially the women in identifying
their health problems. The people can be mobilised to improve not only the curative
care but even more so in health education as well as in the prevention and control of
the diseases that originate in their environment. The people have the greatest interest
in improving the conditions that affect them and their children. This would also be an.
impetus to the overall improvement of the community of which they are a part.
The World Health Organisation was advocating Community Involvement in
Health(CIH) as a pre-requisite for solving the health problems of the developing
countries (Community Involvement in Health Development: Challenging Health
Services-Report of a WHO Study Group WHO Geneva - 1991). WHO study group
reports says that “A critical step will be the decentralisation of health services and
the corresponding strengthening of the local health services that will serve as the
basis for CIH” and further “Structural changes in health systems will be
necessary to support the CHI process. These changes include: decentralisation
of planning, management, and budgeting
The administration of the Primary Health Centres, Community Health Centres and the
Taluk and District Hosptials are already handed over to the local bodies. Moreover,
thanks to the on going Peoples’ Campaign for Decentralised Planning, there is a
tremendous scope for solving the health crisis through which Kerala is passing. And
CIH as advocated by WHO has become an achievable objective in our state.
PANCHAYATH RAJ AND THE HEALTH SECTOR
The possibilities that are opened up with the financial and administrative
decentralisation of the health sector and the People’s Campaign for Decentralised
Planning are the following:
1. The control of infectious diseases and even the prevention, early detection, and
management of the life style diseases can be achieved only by strengthening the
primary and secondary level health care facilities. With the local bodies in control,
this can be achieved with better community involvement.
2. Once the primary and secondary health care facilities are improved through the
local bodies , the tertiary care centers like the medical colleges can entirely
concentrate on medical education, research, and tertiary health care.
5
3. The problem of resource constraint in health sector can be solved with a more
need-based reallocation of resources and generating local resources through
community participation.
4. A better relationship between the health workers, people’s representatives, and the
people at large can be accomplished.
5. Once the public health system is reinforced the poor people who cannot afford the
private health services will be benefited social equity in health care will be re
established.
6. There are provisions in the Panchayath Raj Act which can be invoked for the
social control of the private sector.
An analysis of the experiences of the campaign so far shows that the we are definitely
moving in the correct direction in solving the rural health problems of the state.
DECENTRALISED PLANNING : ACHIEVEMENTS
The concrete achievements realised so far can be summarised as follows:
1. As evidenced by the participation in the Gramasabhas, Development Seminars,
Task Forces, Voluntary Technical Corps, and voluntary contributions both in terms of
money and labor power, community participation in local development has become a
reality in Kerala. More than anything else the sense of optimism generated among the
people by the campaign is the greatest achievement of the decentralisation process.
2. It was feared by many that, the health related projects would be confined to
building more and more curative centres. It is true that there is a contradiction in
health between the felt and real needs of the people. While only through a preventive
and promotive approach the basic health problems can be solved, there is a growing
demand for more sophisticated curative health facilities from the community.
However, the preliminary examination of the health projects show that majority of
them are for sanitation, health education and for improving the primary health care
infrastructure in the villages. Of course, there are instances of unrealistic and
inappropriate demands for hospitals. However, the thrust is on prevention and
improvement of the existing health care facilities.
3. With the reallocation of plan funds within the health sector, the problem of
financial constraints of the health sector appears to be solved. Of the 6000, Crores of
rupees allotted to the local bodies for the Ninth Five Year 30% can be spent on social
services sectors like health, education, water supply, sanitation etc. Of this at least 500
crores are available for heath sector. In the first year, the projects were mainly on
water supply and sanitation. Nevertheless, the estimates from the first year projects
shows that the local bodies are likely to spend at least 340 crores exclusively on health
and health related projects. It may be interesting to note that the departmental
allocation for Ninth Plan amounts to 310 crores. Thus, the primary and secondary'
health care institutions have been given adequate funding for improvement of the
services rendered by these institutions. Once these facilities are better organised, the
department can spend the fund allotted to them exclusively for improving the tertiary
care facilities. Over all compared to the Eighth Plan, health funding has increased
from 2.37 to 4.03 percentage of the total plan allocation.
4. A belter working partnership is developing between the doctors, the health workers..
the Panchayath functionaries, and the people in the rural areas. Thf health •worker#'
now feel that with out bureaucratic red-tapism and the involvement of the higher
authorities improvements can be made at the Panchayath level itself. For the first time
in the history of the medical profession, the doctors working at the rural areas have a
role in the planning of the health care set up where they are working. This has given
them a sense of participation and professional satisfaction.
5. The autonomy with in the decentralised set up has offered the local bodies to
formulate and implement a number of imaginative community based health
programmes. From organising blood donation camps to issuing health cards to the
people of the Panchayats and conducting health surveys to study the health problems
of the local community a number of innovative programmes are being accomplished
by the local bodies.
THE PLANNING BOARD INITIATIVES
For the sustainability of the decentralised approach in health planning, horizontal and
vertical integration of the health programmes at various levels is needed. Moreover,
the decentralisation concept should be further popularised and institutionalised. With
this in mind, with the help of the health department and the professional organisations
the planning board organised health services doctors meeting in all the districts. It was
quite gratifying to understand that a large number of doctors are actively involved in
the decentralisation campaign by preparing health projects, participating in the
Voluntary Technical Corps etc.
Planning Board also organised an orientation progamme for the faculty and
postgraduate students of the community medicine departments of the medical colleges
and
the
Achutha Menon Centre for Heath Sciences Studies. The conference came out with a
number of recommendations that deserves serious consideration. The major
recommendation is to link the community medicine departments with the functioning
of the primary and secondary level health institutions in the state. Another
recommendation was the formation of a state level health faculty to co-ordinate the
local level health activities. It is also recommended that the health faculty should take
the initiative to organise block level conventions of the doctors, health workers and
the representatives of the local bodies.
It was pointed out that the widely acclaimed Kerala Model of Health that can be
described as ‘good health at low cost’ and based on social justice is passing through a
period of crisis and if unchecked this may lead to an American Model of Health based
on privatisation and the marginalisation of the disadvantaged. The Panchayath-Raj
system rooted in community involvement is poised to change the health scenario in
our state and is likely to conceive a new Decentralised and Participatory Model of
Health Care in our state. In case this becomes a reality then Kerala will bestow
another unique model of health care worth emulating not only by the other Indian
states but also by other developing parts of the world.
7
Indicators
TABLE ONE
KERALAM HEALTH STATUS
1996
Keralam
India
USA
Crude Death Rate
Infant Mortality Rate
Crude Birth Rate
6.3
11
17.7
10
79
29
7
8
17
Male
Female
Life Expectancy
66.8
72.3
57.7
58.1
73
79
(Sources: 1. Health Services Data Government of Kerala 1996
2. World Health Report WHO Geneva 1996)
TABLE TWO
KERALAM MORBIDITY
Acute Diseases
Chronic Diseases
Keralam
NSS 1974
India
Keralam
KSSP 1987
71
83
22
21
206
136
TABLE THREE
UTILISATION OF HEALTH SECTORS
1987
Group
Public
Private
%
One
33
43
Two
25
50.
Three
16
60
Four
8
66
(Group One - Poorest, Group Four - Richest)
(Source Table 2 to 3 Health and Development in Rural Kerala KP Karman etal
KSSP1991)
TABLE FOUR
GOVERNMENT AND PRIVATE SECTOR
1995
Government
Private
1249
4288
No of Institutions
42432
67517
No of Beds
4907
10388
No of Doctors
(Source: Report on the Survey of Private Medical Institutions in Kerala 1995
Department of Economics and Statistics Government of Kerala 1996)
8
TABLE FIVE
PLAN ALLOCATION - HEALTH SECTOR
EIGHTH FIVE
YEAR PLAN
TOTAL
ALLOCATION
HEALTH
SECTOR
PERCENTAGE
5460
120
2.2
NINTH FIVE
YE.AR
PLAN
ALLOCATION
HEALTH
SECTOR
PERCENTAGE
10100
309.4
3.06
TABLE SIX
PLAN ALLOCATION- HEALTH SECTOR
(LOCAL BODIES)
LOCAL
BODIES
ALLOCATION
HEALTH
SECTOR
(EXPECTED)
HEALTH
SECTOR
TOTAL
TOTAL NINTH
PLAN
ALLOCATION
500+309.4
6000
500
16100
809.6
( Source: Planning Board Documents: 1999)
HEALTH
SECTOR
PERCENTAGE
CROSSCURRENTS
The poverty at Amartya Sen
Even the "sensitive" Sen has failed to understand "ecological poverty"AN1L AGARWAL
this is the time when paeans are being sung about the “poverty
economist” Amartya Sen because of the Nobel Prize for
economics. It is, therefore, probably churlish for an Indian to
point out his grave shortcomings. But I have chosen to do so
because there could not be a better moment to point out a
weakness that most economists share, including the best of the
best, namely, Amartya Sen.
Sen made his mark by pointing out that people often die of
hunger not because there is a shortage of food but because
there is a shortage of‘'entitlements”. He has, therefore, talked
about welfare systems that create those entitlements and that
globalisation must be accompanied by “social security safety
nets”. So far so good! Hut this analysis restricts itself only to
an exploration of a phenomenon (hat can be described as
"economic poverty” and which Sen's professional
colleagues — namely, economists — love to study. But
another phenomenon which I would like to describe as “eco
logical poverty” is rarely understood by them, including the
"sensitive” Sen, as many newspaper columnists describe him.
1 first met Sen at a meeting in Stockholm in 1987 where
we were part of a panel to discuss the relevance of the justreleased Brundtland Commission report which called for
sustainable development. I was appalled and livid to hear Sen
make the remark that environment has precious little to do
with poverty, the biggest problem facing the developing world.
What he was saying was not just contrary to my own world
view but also my face-to-face experiences with innumerable
villages facing the dreadful droughts of the mid-1980s which
the then Rajiv Gandhi government was trying to fight bravely.
I told Sen that he seemed to be quite ignorant of the realities of
poverty in his own country, but he could not understand what
I was saying. In fact, another eminent Indian economist,
Partha Dasgupta, who heard our debate, tried to bring us
together that evening. But I came away feeling that Sen could
not comprehend what I was saying.
Exactly 10 years later I was to get another rude shock. This
time it was from Mahbub ul Haq, another economist with a
human face and a friend of Sen’s. Haq is known for his work on
a new index to measure “human development” for which he
has received considerable support from Sen. Arguing that the
World Bank’s (wb’s) exclusive dependence on “per capita
income” as the main indicator of development was incorrect,
Sen and Haq worked with the support of the United Nations’
Development Programme (undp) to produce a “human deve
lopment index” which included other factors like infant mor
tality and literacy. In 1997,1 was asked to address the undp’s
executive board on the subject of “poverty and environment”.
57rtmber 15. 1998 Down To Earth
1 talked at length about how villages like Sukhomajri and
Ralegan Siddhi had made an extraordinary economic transfor
mation from destitute to prosperous villages through good
environmental management. Haq, who was chairing the pre
sentation, stunned me by say
ing, in his summing up,
this, it was UNDP assistant administrator, Anders
Wijkman, who immediately intervened to say
that I had actually said exactly the opposite. Haq
was obviously so lost in his outdated beliefs that
he had not even cared to hear what I was saying.
It is indeed appalling that it is Third Worlders
like Sen and Haq who advise First Worlders on
how to give aid to the poor.
The unfortunate part is that Haq and Sen
are not the only “insensitive” economists who
go buzzing around about “poverty” but know
precious little about how to tackle it.
Fortunately, the situation is slowly changing
4Sl
. 411 3T
CROSSCURRENTS
and the subject of “ecological poverty” is being understood a
little more. The Nobel Prize committee will one day
have to make amends by rewarding another and more
sensitive economist who helps the world understand this
far more critical problem.
The wb estimates that nearly a billion people live in
absolute poverty. More than half these people still live within a
biomass-based economy. For these people, their immediate
environment yields — the Gross Nature Product — are far
more than the Gross National Product which economists love
to measure and swear by. But these people suffer from an acute
“ecological poverty” because of the heavy degradation of their
environmental resource base. The trees and grasses have gone,
the land has eroded and the hydrological cycle has been
disturbed. As a result, the basics of their economy have
disappeared. Agricultural production has become precarious
and animal care is equally threatened. Life has, therefore,
become an unending trail of misery and hard labour resulting
in distress migration, growing slums in increasingly unman
ageable cities and atrocious labour conditions.
While all western economists are at their wit's end about
how to deal with this poverty — in the Sahel or central India,
for instance, villages like Sukhomajri and Ralegan Siddhi have
shown that if communities are empowered to manage their
natural resource base they can easily restore their environ
ment. In other words, they can get rid of their "ecological
poverty” and, with their newfound ecological wealth.
start creating economic prosperity. Ralegan Siddhi was
a totally destitute village with a degraded environ
ment, distress migration and bad social conditions.
Today. Ralegan Siddhi has no distress migration
and it exports vegetables to West Asia. And all this
The unfortunate part is that Haq and Sen are not
the only ‘insensitive’ economists who go buzzing
around about ‘poverty’ but know precious little
about how to tackle it
has been achieved through ecological management. But this
was not a Senish project of simple “social security safety nets”
and dole. It was a scheme of “community empowerment”
together with a “social security safety net”. Studies have shown
that in several other lesser-known projects, where efforts were
made during the 1980s to reverse ecological degradation
through “community empowerment”, there was a reduction
in distress migration. This shows that if India wants
labour conditions to improve and cities to move towards
manageable conditions, then the country must address itself to
the problem of “ecological poverty”. The successful effort
of the Madhya Pradesh government in Jhabua to develop a
watershed programme based on these principles shows that
they can be replicated even on a large-scale.
The greatest of all "poverty experts" in India is a totally
unsung Indian. A Gandhian social worker, V S Page is hardly
known outside his state of Maharashtra. It was Page who, based
on the results of his field projects carried out in the 1960s,
developed the country’s first entitlements scheme — the
Employment Guarantee Scheme (lies) of Maharashtra — in
the early 1970s. The scheme was truly pioneering in concept
and practice and showed that even a very poor country like
India could provide a minimum social security net for its
people. It was only after the launch of this scheme that
the country could take the social sting out of the late
1970s and 1980s droughts. The central government did
not pick up the courage to start a nationwide EGS but it
did set up rural employment schemes on the same
lines. Financial support to them has remained an
important item on the political agenda.
Spurred on by success stories like that of Ralegan
Siddhi during the mid and late 1980s,an understanding
began to grow about the importance of dealing with
“ecological poverty". The government has increasingly
tried to use these rural employment schemes to build
“ecological capital” and thus get rid of “ecological
poverty”. Thus, considerable experience has been
gained in dealing with “ecological poverty". The overall
failure of this effort, except for the success of Madhya
Pradesh, has clearly shown that a safety net will remain
a perpetual exercise unless it is accompanied by “community empowerment”. And state governments have
SggSjSjK rarely shown the will to do so beyond political
rhetoric. But things can’t always be bad. I
am convinced that they will change,
howsoever slowly and painfully.
I am sorry, Dr Sen, but I had
to say this because I think the
challenge we face is quite different
than the simple one you have
put forward. ■
Down To Earth December 15, 1998
W>ld Health Assembly Spe^il
/ >lr
iff
To Our
No. 4
21 May 1999
Good health is a question of
Ctoser cooperation the way to
priorities, not income - Dr Sen better heaSth ~ Dr BrundWand
f/f- inancial conservatism
S- should be the nightI marc of the militarist,
not the doctor, or the school
teacher, or the hospital nurse,”
Nobel Laureate Amartya Sen told
the World Health Assembly
Tuesday.
Professor Sen, a scholar from
India whose work produced a
new understanding of the catas
trophes that plague society’s
Dr Sen speaking to delegates
Tuesday
poorest people, won the Nobel
Economics Prize last year for his
contributions to welfare econom
ics, which help explain the eco
nomic mechanisms underlying
famines and poverty. Sen “re
stored an ethicaJ dimension to the
discussion of vital economic
problems,” the 1998 Nobel cita
tion said.
The 65 year-old economist.
Master of Britain’s Trinity Col
lege in Cambridge (UK) and
former Lamont University Pro
fessor Emeritus al Harvard Uni
versity, said that fast economic
growth has helped improve
health in some countries where
the growth is wide-based and in
come is used to expand health
care education and social securi
ty. However, oilier countries have
used "support-led processes that
work through a programme of
skilful social support of health
care, education and other relevant
social arrangements” to enhance
living conditions and reduce mor
tality rales, even without much
economic growth”, he noted.
Because of this support-led
process, he said, “Despite their
very low levels of income, the
people of Kerala (India), or Chi
na, or Sri Lanka enjoy enormous
ly higher levels of life expectan
cy than do the much richer popu
lations of Brazil, South Africa and
Namibia, not to mention Gabon.”
"And yet, when it comes to
health and survival, perhaps
nothing is as immediately impor
tant in many poor countries in the
world today as the lack of medi
cal services and provisions of
health care,” Professor Sen said.
Citing a recent study called “In
fections and Inequalities: The
modem plagues,” by Paul Farm
er, he said “a major difference can
be brought about by a public de
termination to do something
about" pervasive deprivation of
biomedical services, both for eas
ily treatable diseases like cholera
and malaria and more challeng
ing ailment like AIDS and drugresistant Tuberculosis.
The issues of social alloca
tion of economic resources “can
not be separated from the role of
participatory politics and the
reach of informed public discus
sion,” he said.
“The public has to see itself
not merely as a patient, but also
as an agent of change. The pen
alty of inaction and apathy can
be illness and death,” Professor
Sen concluded.
he World Health Organiza
tion will work closely with
Member Stales and other
UN organizations to substantial
ly improve the health conditions
of (he world's poorest.
“We arc not aiming at mod
est gains,” WHO Director-Gener
al Gro Harlem Brundtland told
delegates al the 52nd World Health
Assembly - the Organization’s
annual “shareholders’ meeting”.
“In East Asia, life expectancy in
creased by over 18 years in the
two decades that preceded the
most dramatic economic take-off
in history. Repeat these gains and we could be launching a new
leap forward for human progress
and development.”
In addition to the formal res
olutions adopted at every Assem
bly, this one will also contain
round-table discussions on key
health questions, a lecture by
Nobel Laureate Amartya Sen on
health’s role in development, and
a large number of associated ac
tivities - ranging from a World
Bank report on the economics of
tobacco to briefings on WHO’s
role in relief work in the Balkans.
In her speech to the Assem
bly, Dr Brundtland spell out the
role WHO will play in the years
to come to ensure that the one
billion who have so far been ex
cluded from the health “revolu
tion” of the second half of (he
twentieth century will see dras
tic improvements in their health
in the coming decade. Having re
structured Headquarters and
brought about a realignment to
ensure that regional offices and
Headquarters share priorities and
work effectively, WHO is now
ready to focus on the challenges
ahead. Dr Brundtland said.
She said WHO is working
T
“Health is a fundamental human right,” Dr Brundtland said.
“We need public voices to speak out for all those who are
denied their human rights to health. “You can count WHO as
one (of these voices).”
South African anti-smoking laws to stay
outh Africa’s health minis
ter, Dr Nkozasana Zuma,
has reiterated her country's
determination not to bow to pres
sure from the powerful SouthAfrican tobacco lobby smarting un
der the country’s tough new anti
smoking laws.
The legislation, recently
signed by President Nelson Man
dela, bans die advertising of to
bacco products. It also bans
sports and arts sponsorship by
tobacco interests, the use of to
bacco trade marks on other prod
ucts, and smoking in public plac
es, including the workplace.
"They (die tobacco industry)
are putting a lot of pressure on
S
us through the media, sometimes
attacking me personally and try
ing to mobilize the trade unions
against us ...but our position is
that everybody must comply
(with the anti-smoking laws),"
Dr Zuma told reporters.
Addressing charges by the
tobacco lobby that the new laws
violate the constitutional princi
ple of freedom of expression, she
replied: “ Freedom of speech is
not an unlimited right; there arc
limitations to every right and we
strongly feel that this is an area
where the limitation has to be ap
plied.”
The Minister said govern
ment would work with players in
the tobacco industry to help them
diversify into other equally prof
itable ventures. Tobacco is a
multi-billion Rand industry in
South Africa, employing some
200,000 people. "We did a study
on the economic implications of
doing something or doing noth
ing about tobacco use in our
country, and came to lire con
clusion that the economic conse
quences of doing nothing are
much more dire,” she said.
With the introduction of to
bacco advertising bans, South
Africa joins more than 22 others
with complete or near-complete
advertising bans, in line with a
May 1990 WHO resolution.
South African Health Minister Dr Nkozasana Zuma Monday
was honoured by the World Health Organization for her efforts
to rein in the tobacco industry and control the tobacco epidemic
in South Africa.
more closely with Member
Stales, both through increased
day-to-day cooperation with the
missions in Geneva, by establish
ing a closer and more strategic
work with WHO’s Executive
Board, and through clearer polit
ical leadership of the World
Health Assembly.
“Il is my hope that discussions
and decisions during (he coining
days will send a clear health nies-
Dr Brundtland addressing the
Assembly Tuesday
sage to the world,” she said.
She added that the dialogue
initialed with the World Bank and
the International Monetary Fund
over the past months had been
fruitful and would be intensified.
A key factor in WHO’s new
priority-selling is to emphasize the
economic benefits from improved
health and the need forcosl-ellcclivc, equitable health systems.
“A five year difference in life
expectancy may yield an extra
annual growth of 0.5 per cent. Il
is a powerful boost to economic
growth,” Dr Brundtland said, re
affirming conclusions of the
World Health Report, which she
presented to Assembly.
Editorial
2
Smallpox eradication
2
Mental health problems
on the rise in Mongolia
2
New information products
for "one WHO"
2
Amartya Sen on
development and health
3
World Bank launches
report on the economics
of tobacco control
4
Twenty-two nations
discuss ways to put health
at the core of
development work
4
To Qur Health - 21 May 1999
Amartya Sen on
development and heafth
L 1
id
d
By Adrea Mach
In her address to the World Health
Assembly, Dr Brundtland lauded
keynote speaker Professor Am
artya Sen, 1998 Nobel Laureate
in economics, as "having placed
poverty and development at the
core ofeconomic theory and, link
ing the social and economic di
mensions of human develop
ment". The interview below is a
TO OUR HEALTH exclusive in
terview with Professor Sen.
Development economics fo
cuses on "the world’s most
enduring problem”, persistent,
widespread poverty. Where
does health fit into the pover
ty picture?
If one thinks of poverty only
as low income, then the health link
is indirect: itiseasiertoeamaliving and alleviate poverty when
one is in good health. On the oili
er hand, if we think of poverty as
basic deprivation of the quality of
life and of elementary freedoms,
then ill health is an aspect of pov
erty. Bad health is constitutive of
poverty. Premature mortality, es
capable morbidity, undernourish
ment are all manifestations of pov
erty. I believe that health depri
vation is really the most central
aspect ofpoverty.
You are keen to reduce poverty,
especially through better edu
cation and improved health
coverage, so that entire socie
ties may benefit. But if we do a
reality check, what about coun
tries like India? Is universal
health coverage really feasible
over the short to medium term!
Or is this an idealistic illusion!
Indeed, it would be quite dif
ficult to provide sophisticated
medicine for every person in In
dia. But basic medical care can be
guaranteed to every human being,
even in a poor country like India.
Some areas of India are much
better provided in terms of health
care than others. For example,
Kerala has very wide health care.
Now Kerala is not any richer than
the rest of India; it’s in fact slight
ly poorer on average. If Kerala can
do it, the rest of India also can. In
fact, in terms of survival to ma
ture ages, the African American
population in the United States,
though many limes richer than the
population of Kerala, actually has
a lower chance of survival to ma
ture ages. Low per capita income
is not really such a barrier. That's
the first thing.
Secondly, basic medical care
is very labour-intensive. In a low
wage economy, the state has less
money to spend on health care,
but it also needs less money to
spend on the same amount of
health care because the cost of
medical services is lower. That
is a very important economic
consideration. So if you do a re
ality check, you should consider
how much the state must spend
but also what the expenses are
and by how much good econom
ic organization can reduce them,
building on the low wages that
make health care that much
cheaper. Universal health cover-
age is no Utopian illusion at all,
even for very poor economics.
What is the relative impor
tance of public vs. private sec
tor funding, especially for re
ally impoverished countries?
The importance of the public
sector in fields like health care is
very well established. There is no
way die private sector can do as
much. Those who think privately
financed medicine could do it all
are mistaken. Private insurers
don’t have the incentive to cover
the most vulnerable people be
cause it’s always against the in
terests of an insurance company
to cover someone who is more
likely to become ill.
However, I quite agree that
we have to consider how to im
prove the quality of public sector
healtli care delivery. The market
gets its incentives from die profit
motive, but it is rather neglectful
in the field of health care. When
it comes to the public sector, you
have to provide die same incen
tive in oilier ways. That requires
active public discussion on health
care provision; it requires constant
vigilance about the quality of hos
pital, medical, nursing services,
etc. This incentive has to be pro
vided through the medium of pub
lic discussion and criticism.
In the past, health has often
been both isolated and isola
tionist. How can health now
be mainstreamed into the
broader development agenda?
Health should be seen as an
integral part of die development
agenda. There is, first of all, die
basic recognition diat deprivation
of healdi is an aspect of under
development. Just as for the in
dividual, not having medical
treatment for curable ailments
constitutes poverty, similarly, for
a country, not having adequate
health arrangements is a part of
underdevelopment. So you have
to place the issue of healdi care
right al die centre of die devel
opment agenda.
Secondly, there are enor
mous interdependencies between
different kinds of deprivations.
For example, the deprivation of
health is bad even for the econo
my because people’s productivi
ty depends on dieir level of nu
trition and health. The function
ing of the economy suffers from
illness-related absenteeism.
One of die Director General’s
priorities is Roll Back Malaria. As
someone who did suffer from
malaria veiy early in my life, I can
tell you dial it’s extremely debili
tating. It is important to see the
interconnection and the impact of
health and health development,
not just on die lives diat human
beings directiy lead, but also what
they can do as productive agents
in the economy and as agents of
social and political change. These
are all part of the development
agenda.
In some Indian states, good public health care has ensured health indicators that arc on
par with those of much richer countries
Today’s world is characterized
by increasing privatization of
medical care. For example,
consider the US model where
costs are going up, quality is
going down and more and
more people are being left out.
Today 16% of America’s GDP
is consumed by health related
expenditures and even this
doesn’t do the job - there are
still 44 million Americans
without health insurance. If
this type of model spreads,
where will it lead in terms of
the goal of Health for All?
That aspect of American
medical arrangements is not one
of glory. There are others which
are quite glorious: the statistics
of survival after the diagnosis of
cancer, for example, show almost
twice as many years in America
as in, say, Britain. That is some
thing that Americans do right.
That is a characteristic of the ef
ficiency of the system for those
who can afford it.
But the glaring defect of (lie
American system is that it ne
glects lots of people who simply
cannot afford it, like those who
don’t have medical insurance.
You mentioned the number 44
million without medical insur
ance - that figure seems to be go
ing up relentlessly. It is not just
specialized medicine; people
may be deprived of even die most
elementary health care.
One has to recognize that the
nature of the market economy
makes it very efficient for certain
types of production, like stand
ard types of industries. But it’s
not very good for other kinds of
economic activity, particularly
medicine.
There are two reasons: one
is that many of the results of med
ical care have the feature of be
ing what economists call public
good which affects not only the
well-being of that person but also
of others, for example with infec
tious diseases which arc conta
gious to others. In dealing with
public goods, markets arc notori
ously defective.
Second, the pattern of risk in
medicine makes die market less
efficient because, as I discussed
before, it’s always in the interest
of private insurance to try to get
out of covering those who are
most likely to need medical care.
But these are people for whom
medical care is most important.
It’s a question of trying to tain
the efficiencies that American
medical systems have — one
should not deny (hose; they are
radically important. If you have
a serious illness, you have a very
good reason to go to America for
treatment - if you can afford it.
And yet it’s not very benign in
terms of its coverage of the poor
est. So we have lessons to learn.
The way you put it, in terms of
the limits of the market economy,
is a very good way of understand
ing it. Wc must pay adequate at
tention to the role of public poli
cy in dealing with medical care.
You have emphasized “the
abiding role of values as central
to growth and development,”
saying that “development is a
measure of human freedom”
and that “health is crucial to
freedom”.
Yes, I have a book coming
out in September which is called
Development as Freedom. It’s an
attempt to see development as en
hancement of human freedom. 1
argue that freedom is the prima
ry end of development. Develop
ment isn’t about raising GNP. No
one wants money for its own
sake. One wants money for some
thing else, including good health.
To be free to lead a good life, not
to be cut off prematurely, not to
have to suffer escapable ailments.
Freedom of different kinds is con
stitutive of development.
Freedom is not only the pri
mary end of development, it
is also its principal means.
Freedoms arc of different kinds
-social opportunities (which in
clude health care), market and
economic opportunities, and po
litical freedom in (he form of par
ticipation in society and decision
making. In different ways,
freedoms alTccl our lives, from
different ends. But as it happens,
they are highly complementary.
For example, you do not have
famines in a democratic country
because the government could not
face the polls or the criticism of
opposition parties if it had a fam
ine. There are other complemen
tarities like social opportunities in
the form of health care and edu
cation which make it easier for
people to participate in a market
economy, especially in a rapidly
globalizing world. Freedoms of
different kinds feed each other,
support each other, consolidate
each other.
I would like to argue that
freedom is very central to devel
opment, both as ends and as
means. Il’s the complementarity
of different kinds of freedom
which makes the analysis of “de
velopment as freedom’’ a partic
ularly fruitful thing to pursue.
Consolidating freedom of one
kind helps consolidate freedom
of other kinds. This is a very cen
tral issue in facing the challeng
es of the 21s' century. The differ
ent aspects of freedom must in
fluence the agenda of the com
ing century.
Professor Amartya Sen is Mas
ter ofTrinity College, Cambridge
and isforme rPresident ofthe In
ternational Economic Associa
tion. the American Economic
Association, the Indian Econom
ic Association, and the Econo
metric Society. The Royal Swed
ish Academy awarded him (he
Nobel Prize in economics in 1998
by citing his work in welfare eco
nomics and, in particular, on so
cial choice theory, poverty and
inequality.
SOUTH ASIAN DIALOGUE ON POVERTY AND HEALTH
15* To 18* November
Bangalore
This folder and bag should contain :
01.
The Framework of the Dialogue (a note)
02.
The Final Programme
03.
The list of Participants
04.
A Who is Who Document (Participant profile)
05.
The Community Visit - Objectives
06.
Some notes on the Community Visits
07.
The Summary of the Opinion Survey
08
Suggested Questions for the Group Discussion
09.
Learning from the Community - A Checklist of Parameters for the report
10.
A Bibliography of the reading material received for the dialogue
11.
A CHC pamphlet
12.
An International Poverty and Health Network (IPHN) Note
13.
A note on World Health Organisation - HSD
14.
To Our Health - The newsletter of WHO - World Health Assembly Special (Pg. 1 & 3)
15.
An Invitation Card for Cultural Programme and Special Dinner on 17* November, 1999
16
Symposium Paper 1 - Poverty, Disease and National & International Power structure - The Case of India by
Prof. D. Banerji, India.
17.
Symposium Paper 2 - Poverty and Development Paradigm - People’s Perspective by Prof. Mathura Shrestha
and Dr Indira Shrestha, Nepal.
18.
Symposium Paper 3 - Equity in Health Care - A Formidable Challenge for Sri Lanka (Synopsis) by Ms.
Myrtle Perera, Sri Lanka.
19.
Symposium Paper 4 - Crisis in Governance of Public Health System in Bangladesh A Challenge of
Humane Govenancc (Synopsis) by Dr. Abul Barkat, Bangladesh.
20.
Cartoon
Additional Background Papers
21
Health and Poverty in War by Dr. N. Sivarajah, Sri Lanka.
22.
The Poverty of Amartya Sen by Mr. Anil Agarwal, India.
23.
An Integrated approach to Community Health : The Sarvodaya experience in Sri Lanka by Dr. Vinya
Ariyaratne, Sri Lanka.
24.
A Report on The Rajiv Gandhi Missions - Government of Madhya Pradesh.
25.
Strengthening Community Based Health Care in Madhya Pradesh through Decentralised Management of
Health Services by Mr. R. Gopalakrishanan, India.
.
26.
Peoples Campaign for Decentralised Planning and The Health Sector in Kerala by
27.
A New Health Policy for Health Sector Reforms by Mr. Ravi Duggal, India.
28.
Poverty and Health : Universal Abuse of Human Rights by Dr. Sunil Kaul, India.
29.
A Note from Mr. B.S. Lamba, India.
30.
Relevance of Ideas and Mass Mobilisation for the Removal of Poverty and Inequality by Dr. Devaki Jain,
India.
31.
Poverty and Health; Reaping a Richer Harvest - A book Notice
32.
Special Issue - Health and Equity - Health for the Millions, New Delhi.
33.
Special Issue - Community Health : Search for a New Paradigm - Health Action, Secunderabad.
34.
A map / pamphlet on Bangalore
Others
35.
Pad, Pen, Badge
Dr. B. Ekbal, India.
Civil Society Initiatives
5J
.
-
BANGLADESH .
Grameen Bank: credit to the poor
The Grameen Bank is one of the most successful experiments in
extending credit to the landless poor. Since 1976, it has empowered
over two million villagers in Bangladesh, mostly rural women,
through the provision of small loans. The Grameen Bank idea
has already been replicated in forty countries worldwide.
This world-renowned programme started rather modestly
m the village of Jobra, Bangladesh, twenty years ago. It was the
brainchild of Professor Mohammad Yunus who realized that
lack of access to credit was the main hurdle in the progress of
the rural poor.
brom its inception, the programme had some very
i^Pvative features. First, no collateral was required from the
poor. Individuals were asked to organize themselves into groups
of five. The individuals in the group gave collective assurance
for each other so that loan repayment became a collective
responsibility. Second, credit was provided to the rural poor
who owned less than half an acre of land; ninety-four per cent
of these were women. Disregarding popular belief, women were
considered more bankable and more trustworthy. This trust
was amply rewarded through a recovery rate of ninety-eight
per cent on all loans advanced to women. Third, the loans were
small (an average of S100 each) and carried no interest subsidy.
In fact, they were given at a much higher interest rate than
bank loans in the market, reflecting the extra administrative
cost of small loans. Fourth, the poor were required to put aside
some saving—at least one taka (US 2.5 cents) a week. This
encouraged the habit of self-reliance among the poor. Fifth,
the bank went to the poor, rather than waiting for the poor to
come to the bank.
By July 1996, the Grameen Bank had extended its services
WIR 5,78 3 villages. Its membership had grown to over 2 million,
of which 1.94 million were women. It had extended small credits
amounting to S1810 million. The small savings of poor villagers
added up to 4819 million takas (S128 million).
The Grameen Bank is now experimenting with other
initiatives. Recently, the Grameen Trust initiated the process
of creating a S100 million People’s Fund to finance replication
of this experiment in other developing countries. Starting from
the small village of Jobra, the Grameen Bank has become a
worldwide phenomenon.
.T?
-
7LZS17773bANGLADESHJ
BRAC: community development for the poorest
of the poor
Since 1972, the Bangladesh Rural Advancement Committee
(BRAC) has fought against malnutrition, illiteracy, disease,
population growth, and unemployment in the villages of
Bangladesh. At first, its activities were confined to the
resettlement of refugees after the blood-soaked birth of the
country. By 1976, BRAC had started to focus exclusively on
the poorest of the poor: the landless, small farmers, artisans,
and vulnerable women. By 1995, BRAC had emerged as one of
the largest NGOs in the world, covering sixty out of the sixtyfour districts of Bangladesh, with a total membership of 1.5
million, 85 per cent of them women.
Every village in which BRAC works has two Village
Organizations (VOs), one each for men and women. Only the
landless, or those owning less than half an acre of land, are
eligible for membership. Members are encouraged to find
solutions to their own problems and to join hands to pursue
such solutions. Small credits are given without any collateral
to the landless poor and to marginal farmers. The borrowers
are asked to save at least two takas per week as well as to deposit
five per cent of the loan they take from BRAC in their saving
account. Currently, BRAC is operating several income
generating projects, such as poultry farming, fisheries, and the
cultivation of vegetables.
One of the outstanding successes of BRAC is a non-formal
education programme which was started in 1984. BRAC has
two school models: one for 8-10-year-old children and the other
for 11-14-year-olds. There is one teacher for every thirty-three
students. The students are taught by the same teacher through
out the three years. Over 72 per cent of the students are girls,
while 95 per cent of the teachers are women. The distinguishing
features of this programme are: flexible school hours, a relevant
curriculum, motivated teachers, reasonable class size, commu
nity support, involvement of parents, and a system of intensive
supervision. BRAC has established over thirty thousand schools
which accommodate nearly one million students.
BRAC has also started several programmes in the health
field. Its Oral Rehydration Therapy programme is implementing
a nation-wide battle against diarrhoea. 99 per cent of mothers
in Bangladesh have been given training by BRAC workers,
enabling them to treat diarrhoea at home. BRAC is an out
standing success story of a nation-wide programme of commu
nity development to benefit the poorest and most vulnerable
sections of society.
"-5"3 — • ■
•;—■
-■■■-.■ -77-7.;^BANGLADESH " ■
Proshika: skills for the poor
Proshika, a nation-wide NGO, has been active in the field of
rural development since 1976. By 1990, Proshika had a
membership of over 20,000 people, half of them women. Its
operations extended to more than 3,000 villages in twenty-two
districts of Bangladesh.
Proshika has been engaged in imparting formal and nonformal education and practical skill-training to the rural poor.
By 1990, the total number of participants in these training
courses was 46,000 men and 76,000 women. Practical training
was imparted to the participants, enabling them to obtain
employment in the surrounding rural communities. During
Development by the People
37
j Civil Society Initiatives j
the fiscal year 1990, the activities of Proshika had reached a
level where 5S million takas (nearly $1.5 million) were disbursed
for employment and income-generating activities. Besides skill
training, a health infrastructure programme was also developed,
the chief feature of which was the organization of 446 courses
in health care in which 14,000 group members participated;
and 778 tubewells were installed, benefiting 20,000 households.
Since 1991, Proshika has also extended its activities to urban
areas, training many workers in urban slums. An initiative that
started rather modestly twenty years ago in a few villages of
Bangladesh now has national coverage and a devoted following.
5.4
'
.
.BANGLADESH
RDRS: social literacy centres
The Rangpur Dinajpur Rural Service (RDRS) is an international
NGO working in the northern part of Bangladesh. RDRS has
introduced new social literacy materials, developed out of its
many years of experience with functional education. It has
opened a network of schools in North Bengal and parents have
been motivated to enrol their children because of the practical
orientation of the literacy programme and its close link with
daily life.
Since 1990, RDRS has been collaborating with another
international NGO, Helen Keller International, to provide
nutritional surveillance. It has motivated families to bring their
children for immunization as a part of the Government/
UNICEF Expanded Programme for Immunization. During the
same period, it conducted a thorough review of the Community
Health Unit programme. By 1990, 62 per cent of RDRS
members enjoyed access to safe drinking water and 16 per cent
of the households were using sanitary latrines.
RDRS has also started producing clay and concrete roof
tiles and hollow sand-cement bricks for low-cost housing. It is
now helping with the plantation of trees and the construction
of small bridges and culverts as well.
The experience of RDRS illustrates how functional literacy
at the local level can be a stepping-stone to many other beneficial
community activities on a self-help basis.
•~57s~
y•
Twenty-two landless women entrepreneurs
Civil society initiatives do not always have to be large, or nation
wide, or internationally famous. A great deal can be done at
the local level through collective efforts.
In the small village of Faridpur in Bangladesh, a group of
rwenty-two women, berween the ages of twenty and forty', came
together in the early 1990s to manage an oil-pressing business.
Their motivation was simple but powerful: traditional methods
of oil-pressing were very labour-intensive and rewards from
organized buyers were small when women approached them
individually to sell their meagre produce. These twenty-two
98
Human Development in South Asia 1997
women got together and borrowed 5,000 takas ($1,250) from a
local NGO to organize their own oil extraction enterprise.
Since they were all illiterate, some took literacy training
in order to maintain their own books. And they slowly learnt
the entrepreneurial skills needed to buy and store seeds when
they were cheap and to sell them for the best price through
collective bargaining. And when some social leaders objected,
as profits of powerful elites were threatened, these illiterate
women offered the most cogent and articulate response:
'When we were dying of hunger, our children were
suffering from diseases, we had no homes of our own and we
lived in thatched houses, the village leaders did not feed us, nor
did they help save our children from hunger and disease, nor
did they give us clothes to cover our bodies. These people have
no right to tell us now what to do or not to do, nor do they
have any' right to judge us or condemn our activities.’
_
Now this spirited band of women has designed a pl.^Fo
buy their own oil-pressing machine. It will cost 50,000 takas
($1,250): they have been able to save only 20,000 takas (S500)
so far. But with the collective determination they have already
shown, the day may' not be far off when twenty-two illiterate
and desperately poor women celebrate the birth of a modern
enterprise.
5-6' ’..Z.ZZ'Z
/• ... ’.'.Z-Z'-’Z. INDIA
Working Women's Forum: empowering women in
urban slums
In the 1970s, the living conditions of poor women in the urban
slums of Tamil Nadu, a south Indian state, were characterized
by extreme poverty, unpaid debts, and illiteracy.
The government had started a credit scheme under which
nationalized banks were directed to extend subsidized credit,
at four per cent interest, to the urban poor, without the
requirement of any collateral. But most poor people ^re
unaware of this government offer. The Working Won®
Forum (WWF) was organized in 1977 to enable indigent selfemployed women to take advantage of this scheme.
During the 1980s, WWF 'expanded beyond this credit
intermediary role. It organized its own credit and saving schemes,
on a panern similar to that of the Grameen Bank (see box 5.1),
with collective group collateral, small savings by the poor, and
income-generating micro-enterprises. The rule of collective
borrowing generates peer pressure, which leads to high repayment
rates. Groups are normally formed by' a potential group leader
who has become familiar with the WWF programme and is
competent enough to guide the new members.
Currently, over 50,000 needy women benefit from these
small credit programmes, and the loan repayment rate is 94 per
cent. In many cases, the daily earnings of these women have
gone up three to four times.
Using credit as an entry point, WWF has branched out
into many other social programmes such as day'-care centres,
I
Civil Society-Initiatives
night classes for children, skill-training, health and family
planning, and the organization of advocacy and lobbying efforts.
This civil society initiative has now reached a target population
of 2CC,000 poor women working in the infoimal sector.
'
5.7
_
INDIA
'SEWA: trade union of poor women
SEWA (meaning ‘service’ in Hindi) is a trade union with a
difference. While trade unions normally organize permanent
workers in various occupations to fight for their rights, SEWA
(Self Employed Women’s Association) has organized women
working in the informal sector. These include vegetable vendors,
rag and paper pickers, bamboo workers, head loaders, cart
pullers, and garment workers. Before SEWA was formed in
Ahmedabad in 1972, these poor hardworking women were
totally at the mercy of their employers, often exploited for very
iMfcwages and insecure in their very low-pail jobs.
SEWA has successfully overcome the boundaries of the
caste system in India, drawing its membership from all sections
of society. One-third of its membership tod ty is Muslim and
another one-third belongs to the scheduled tastes.
SEWA has empowered these women by combining the
strategies of trade unions and co-operatives. SEWA has organized
its own co-operative bank and a group life insurance scheme so
that its members can become more self-reliant. It has also started
several skill-training courses to enhance the income-earning
potential of its members as well as providing legal services to
enable indigent women to obtain the benefits of national labour
legislation, which were earlier denied to them.
One of the novel features of SEWA is itsc.ose collaboration
with the government. It has helped the government to organize
several women’s groups under the Development of Women and
Children in the Rural Areas programme. The government has
also used SEWA effectively in extending the outreach of several
programmes to poor women.
5.8
. ~
'
777
JNDIA
Lok Jumbish: a people's movement
The extreme educational backwardness in the Indian state of
Rajasthan led to a unique collaboration between the people
and the state. They established a movement aimed at providing
education for all the people of Rajasthan by the year 2000. The
objectives of LJ are: to provide access to and ensure the
participation of all children in primary schools or non-formal
education centres; to improve the quality of learning; to make
education an instrument for women’s empowerment; and to
provide equal educational opportunities to lower castes. The
strategies used to achieve the above objectives are: (a)
mobilization of people and their involvement in the planning
and implementation of programmes; (b) special emphasis on
rhe education of girls; (c) improvement of the training and status
of teachers; and (d) initiating a comprehensive programme for
reform of the primary education system. Established in 1992,
the project covered a population of 2.2 million during the first
year of its operation.
Through school mapping, micro-planning, training of
teachers, developing women’s leadership, and expanding and
improving schooling facilities, LJ has energized education in
the rural areas of Rajasthan. The overall objective of this
movement is not only to improve education, but also to bring
about a positive change in the attitudes and capabilities of
people, so that ultimately they themselves become responsible
for their own education and empowerment.
5.9
7.
'
7.77
.'. a J ' .. ;/.INDfA '
Jawahar Rozgar Yojana: employment for the poor
Two programmes—the National Rural Employment Prog
ramme and the Rural Landless Employment Guarantee
Programme—were started by the Indian Government in 1980
and 1983 respectively, to provide employment opportunities
to the poor through infrastructure projects which would create
durable assets in the rural areas. In the first few years, these
programmes taught the organizers two main lessons: assets
which are created should be economically viable; local
communities should be involved in deciding what assets to
build. These lessons were learnt well and were reflected in a
merger of both the projects in 1989 into a programme called
Jawahar Rozgar Yojana (JRY).
The central government and the states have shared the cost
of this programme in the ratio of 80:20. The funds from the
Centre to the states are disbursed on the basis of the proportion
of the rural poor in each state. At least 60 per cent of the funds
are spent on wages and the rest on materials. The programme
has large budgetary support: about 21 billion rupees have been
allocated annually between 1990 and 1993.
Considerable success has been achieved under the JRY in
the creation of employment opportunities for about 750 to 850
million man days per year. In addition, one million houses have
been constructed, and 320,000 irrigation wells set up. These
facilities have been developed mainly for scheduled castes and
tribes living below the poverty line. The JRY programme is
currently decentralizing decision-making authority even further,
so that poor people can directly select the assets to be created.
5.io777
77.'
7
77.7/
777
.India ,
Employment Guarantee Scheme
In 1972, the state government of Maharashtra introduced an
innovative Employment Guarantee Scheme based on the
concept of the ‘right to work’. Its basic objective was to provide
productive employment opportunities to the rural areas and
thereby to transform unemployed labour into national capital.
The programme ensured that men and women were given equal
Development by the People
99
Civil Society Initiatives
opportunities to benefit under the scheme.
The programme undertook several development works,
such as soil and moisture conservation, afforestation, social
forestry, and fisheries. The results of this programme have been
very positive. During the first ten years, over 130 million man
days of employment were created each year. The participation
of women was more than 50 per cent.
An important feature of the programme is its flexibility in
adapting to new possibilities. For instance, a special programme
called ‘Shram Shakti Dware Gram Vikas’ (village development
through labour) was introduced. This programme encouraged
optimum utilization of land and water resources, sericulture,
horticulture, and other schemes for small and marginal farmers
below the poverty line.
EGS has greatly helped in alleviating poverty and in
creating productive assets in the rural areas of the Maharashtra
state. It is a good example of government collaboration with
local communities.
5.11
~
.
INDIA
Asha Nagar Leper Resettlement Colony
Asha Nagar is the story of a good experiment gone wrong.
The beginning was quite promising. The District Adminis
tration in Rajnandgaon in India developed a comprehensive
project for the rehabilitation and welfare of lepers. They were
provided group housing, medical facilities, and self-employment
opportunities. Some social services were also provided: a school,
a health centre, and safe drinking water. The project succeeded
in its initial objective: not a single leper was seen begging
anywhere in the town.
And then several problems surfaced. A barrage and a dam
in the area collapsed, leading to the failure of several enterprises,
such as the mulberry plantation and the fisheries. Looms were
driven out of business due to shifts in market demand. Non
repayment of initial loans led to discontinuation of further
assistance from the government. The school was not formally
recognized and upgraded so that the single deputed teacher
left. A well-designed and well-executed project failed for want
of continuous government support and lack of self-help by
target groups. The lepers were back on the streets.
The Asha Nagar Leper Resettlement Colony Project illust
rates that community welfare efforts cannot prove sustainable
unless they are owned and managed by the community itself.
5.12
PAKISTAN
AKRSP: a succesful experiment in community development
The Aga Khan Rural Support Project (AKRSP), a non-profit
organization initiated by the Aga Khan Foundation, started
operating in Gilgit in 1982 to improve the extremely poor socio
economic conditions of about one million inhabitants of the
100
Human Development in South Asia 1997
mountainous northern areas of Pakistan. The programme has
a ‘package approach’: it provides basic education, health services,
and credit; imparts technical skills; and it embarks on major
infrastructure development projects.
The key feature of the programme is the formation of
broad-based, multi-purpose Village Organizations (VOs) in
village communities. The villagers themselves select the physical
infrastructure project, such as a village road or an irrigation
canal. They contribute their free labour and manage the project
themselves. AKRSP trains the people nominated by the VOs
in various skills required for the project. Each phase of project
identification, preparation, and appraisal involves an interactive
dialogue between the villagers and the AKRSP. The first project
is offered as a grant to each VO. This leads to a partnership in
which the VO members commit themselves to the discipline
of the organization, collective savings, implementation, and
maintenance of the project.
As a result of fourteen years of dedicated effort, AKR^ns
now touching the lives of nearly one million people in the
northern areas of Pakistan. About 1,964 Village Organizations
have been formed, covering 77 per cent of rural households.
The total savings of these VOs have now reached Rs 220
million—no small feat in a backward area, where the concept
of personal saving by poor people was unknown and untried
only two decades ago. The small credit programme has benefited
nearly half a million people, with loans worth Rs 518 million.
Extensive physical infrastructure has been built with the active
involvement of local communities.
5.13
'
PAKISTAN
Edhi Trust: the poor man's messiah
If you hear a siren in the dead of the night in Karachi, Pakistan’s
largest city, the odds are that it is neither a police van nor a
government-run service. It is most probably the ambulance of
the Edhi Foundation run by a remarkable man, Abdul
Edhi, known as the Angel of Mercy in the death-haunted streets
of Karachi.
Edhi’s first mass-contact service was in 1957, when he
rented tents on credit and put up camps all over Karachi to
help the victims of a deadly influenza epidemic. A businessman
impressed with Edhi’s work donated Rs 20,000 (S 4,000 at the
time). Edhi bought his first van and started his journey of sendee
to humanity. Soon, people began to inform Edhi of every
accident, and even the police would seek his help.
Now the Edhi Foundation has 320 centres all over Pakistan,
but its operations are still run from a modest office in Karachi.
Edhi is sixty-six, but in times of need still drives the ambulance
himself into some of the most dangerous and violence-prone
areas of Karachi. Edhi’s personal touch has never been missing
from the work of his Foundation, despite the fact that it has
now some 2,000 regular employees, besides thousands of
volunteers.
Civil Society Initiatives
Edhi, with the full support of his wife, runs a national
network of orphanages, hospitals, care centres for the mentally
ill, maternity homes, child adoption centres, and several other
social services. The Edhi Foundation also arranges for the
adoption of abandoned babies. Outside even' Edhi Trust lies a
cradle where women can leave their unwanted children without
identifying themselves. Many innocent lives have been saved
through this thoughtful initiative.
From modest beginnings, the Edhi Foundation has come
a long way. Its present assets are valued at three billion rupees
(around S750 million) and its yearly income is around one
billion rupees. About one-third of this budget is contributed
by Pakistanis living abroad.
The Edhi Foundation is a remarkable example of one man’s
life-long selfless struggle to alleviate the suffering of fellow
i^nan beings.
5.14
PAKISTAN
Orangi Pilot Project: cost effective social services
Orangi, a katcbi abaiii (slum) in Karachi, st as established in
1965. It expanded rapidly after 1971, as neatly one million of
the poorest people crowded into an area with no proper roads,
no electricity, no pipelines for water, few schools, and hardly
any other public services either. The worn environmental
hazard was poor sanitation. Bucket latrines or soak pits were
used for the disposal of human excreta anc open sewers for
waste materials. Diseases spread rapidly in such an unsanitary
environment. People were aware of the problem but did not
know how to solve it. They kept hoping that the government
would solve it for them.
In 1980, Akhtar Hameed Khan, a charismatic leader with
missionary zeal and considerable experience in organizing
community self-help from his previous woik in the Comilla
project in East Pakistan, walked into this environment of
^Rpair. Single-handedly, he convinced the local people that
they could build the necessary sanitation facilities through self
help and at a low cost. This was the genesis of the Orangi Pilot
Project (OPP).
OPP was set up as a modest research institute to analyse the
problems of Orangi and to identify some viable solutions. One
of its first breakthroughs was to discover that the cost of providing
satisfactory sanitation facilities could be drastically reduced. By
simplifying the designs, changing the methods of construction,
eliminating kickbacks and profiteering, providing free technical
guidance to lane managers and enabling them to work without
contractors, the unit cost of sanitary latrines and manholes was
reduced to one-fourth of the conventional cost.
OPP then persuaded the local people that they could tackle
the problem themselves by joining hands. When people realized
that with an investment of only Rs 1,CCO (one month’s average
income), they could reap immediate benefits for their own
health and the health of their families, they decided not to wait
for the uncertain promises of the government to materialize
and started the work themselves.
The results have been extremely impressive. By 1992,
430,000 feet of underground sewerage had been built as well as
more than 28,000 latrines, benefiting 28,000 families. The local
people financed this construction from Rs 30 million of their
own savings, demonstrating how poor people can provide
critical social services for themselves in a very cost-effective
manner.
The success of the sanitation programme in turn led to
programmes for low-cost housing, basic health and family
planning, women’s work centres, school upgrading, and
provision of supervised credits for small family units which
increased production, employment, and managerial skills. Many
NGOs have adopted the basic approach of the Orangi Pilot
Project and external donors (like UNICEF and the World Bank)
have modelled some of their projects on a similar approach.
From modest beginnings, OPP has begun to lead the way for
other self-help community efforts.
5.15
. ' '
PAKISTAN
Baanhn Belk for forgotten people in remote villages
One million people inhabit the Thar desert that spreads across
twenty thousand square kilometres in Sindh. These are the
people who have never seen a metalled road, never used
electricity, never heard of piped drinking water, and never had
much contact with the outside world.
Baanhn Beli—a phrase in Sindhi, Seraiki, and Punjabi,
meaning ‘a friend forever’—is the sole voluntary organization
to have entered the Tharparkar region of Pakistan, with the
aim of improving people’s lives..Established in 1987, its chief
objective is to build an alliance between the disadvantaged
people living in the area and professional specialists from cities
in order to address the most pressing development concerns.
By 1991, with the financial help of the governmentsponsored Trust for Voluntary Organizations and some
international donors, activities started in female education, basic
health care, supply of safe drinking water, computer literacy,
agricultural production, veterinary services, and provision of
small loans to the poor to encourage income-generating
activities and self-employment. By now, over 200,000 people
have benefited from the work of Baanhn Beli in about 200
settlements.
One of the cardinal principles of Baanhn Beli is the active
consent and willing participation of the villagers in the
programmes. For instance, the villagers themselves provide
premises for schools. They identify a male or female teacher
for interviews by the Baanhn Beli organization. They provide
small savings out of their meagre earnings to finance a selfreliant and informal village banking system. This experience
shows that much can be done even in a feudalistic structure, if
local people can be mobilized to organize themselves.
Development by the People
101
Civil Society Initiatives
5.16
PAKISTAN
<
AGHS Legal Aid Cell: fighting for unpopular causes
Asma Jahangir co-founded Pakistan’s first all-female law firm,
AGHS Legal Aid Cell. This Cell became the nucleus of her
crusade to protest against human rights violations in Pakistan
and to' protect the legal rights of the weak and the poor in
society, especially women.
The cases of human rights abuses she takes up make
national and international headlines and provoke several threats
to her life. But her courageous work as Chairperson of the
Human Rights Commission of Pakistan and Chairperson of
her own organization (AGHS Legal Aid Cell) is appreciated
throughout the country and the world over. In 1992, AGHS
Legal Aid Cell was the recipient of the Human Rights Award
of the American Bar Association Section of Litigation.
Her office takes up an average of 350 cases every year. Many
of these cases involve fundamental issues that other
organizations are afraid to touch. For instance, Asma recently
took up the case of a fourteen year old Christian boy, Salamat
Masih, who was accused of having committed blasphemy by
writing disrespectful words against the Holy Prophet on the
wall of a mosque. The child was illiterate but the death sentence
stared him in the face. When Asma took up the case and won
it, saving the child’s life, she received death threats. But this did
not deter her in her efforts to prevent what she considered a
serious miscarriage of justice.
The AGHS Legal Aid Cell not only gives legal aid to
poor people, especially women, it also documents each case
thoroughly and maintains proper records in order to point
out the shortcomings in the judicial system. The Cell also
runs a public campaign through newspapers and posters to
raise national awareness about human rights abuses. It has
awakened the sleeping conscience of many, who now support
its activities.
5.17. •
;
.
; ;
. ' .
PAKISTAN
Bunyad: accelerating female literacy
The Bunyad Literacy Community Council (BLCC) was estab
lished in 1993 to promote literacy, particularly among women.
It started its work from Hafizabad, a backward area in the Punjab,
with the dubious reputation of having a female literacy rate of
only 6 per cent but the highest rate of rapes in the province.
BLCC established several non-formal centres in these remote
areas. Initially, the focus was on the enrolment of both boys and
girls, but it gradually shifted to girls alone. Community
participation became a central feature of these efforts, with the
villagers providing a location for the schools as well as
participating in the selection of local teachers. These teachers
were given proper training at the Bunyad teachers’ training centres.
Bunyad has already established 500 centres in various areas
of the Punjab province, in which 15,000 girls are receiving
102
Human Derthpment in South Asia 1997
education as well as acquiring various life skills. The success of
the programme can be judged by its low' dropout rate at the
primary school level: only 15 per cent compared to a 50 per
cent national average.
Recently, BLCC has adopted a package approach. Besides
education, it has begun to cover areas such as basic health care,
family planning, environmental sanitation, and small credit to
rural women for income-generating activities. It is not clear,
however, whether Bunyad can successfully implement such
comprehensive development packages in view of its limited
financial resources.
The experience of Bunyad raises a fundamental issue. This
civil society effort has come to rely a great deal on the financial
support of one external donor which is about to phase out.
The outstanding w'ork done by this NGO is now threatened
unless funds from some other sources materialize. It shows that
unless an NGO’s activities are supported by the self-help efforts
of the community itself, the sustainability of these acti’.^^s is
always in danger.
. SRI LANKA
5.18
SSM: integration of low-caste families
During the 1950s, a dedicated community leader in Sri Lanka,
A. T. Ariyaratne, took up the challenge of integrating lowcaste families into the mainstream of national life. Now, the
Sarvodaya Sharamadana Movement (SSM) that was started as a
result of this concern covers more than one-third of the total
villages of Sri Lanka.
The Sarvodaya Sharamadana Movement deals with both
income-generation and welfare activities. On the one hand, it
organizes many income-generating programmes for the poor,
such as workshops for mechanical repairs and carpentry, sewing
shops, off-farm activities for small farmers and for the landless.
On the other, it arranges relief and rehabilitation
programmes for the victims of ethnic conflicts and for the^ttf
and the disabled. It also organizes nutrition programmtWBr
pre-school children.
The movement is based on the participation of the people.
It instils a new' sense of confidence among the poor that they
can change their physical and economic environment through
their own efforts.
The movement has created a new leadership which bypasses
the traditional elitist culture of the state. And it has enabled
the weakest and the most ignored groups in society to
participate in the economic, social, and political life of the
countty'.
5.19
?
SRI LANKA
SANASA: credit for the rural poor
The Sanasa movement was started in 1979 when a young social
worker, P. K. Kiriwandeniya, attempted to convert a traditional
Civil Society Initiatives
credit union movement into a non-traditional credit scheme,
in order to reach those rural poor who were excluded from the
formal financial sector.
At that time, 44 per cent of the households in Sri Lanka
were under heavy debt, of which 70 per cent was owed to noninstitutional sources, often from traditional money-lenders who
charged exorbitant interest rates, well above those charged by
formal sector financial institutions. These formal sector credit
institutions had simply failed to reach the rural poor.
Sanasa operates on a voluntary basis. All members
contribute some of their meagre savings to the central resource
pool. This resource pool is then used to give credit in a
systematic manner. The focus is on longer term credit for
productive purposes, not on short-term emergency needs. The
members are required to save and deposit at least one-third of
their loans with the society. The availability of credit for the
^■empowered sections of society has created many innovative
entrepreneurial opportunities in rural areas.
Now, the Sanasa movement has started community
development projects, target group initiatives, and several
environment programmes aimed at the sustainable development
of the rural areas. In addition, many community activities have
been planned to reduce the ethnic strife that has unfortunately
engulfed Sri Lanka.
Sanasa has become a national movement over the last two
decades. The loan recovery rate is over 90 percent compared to
60 per cent in the commercial banks. And, for once, credit is
actually reaching the poorest people in rural areas.
5.20
SRI LANKA
SWM: a movement for the empowerment of women
The Sarvodaya Women’s Movement (SWM) was started in 1987
to empower women as social workers, income generators, and
spiritual leaders. The main programmes of SWM revolve around
^heracy, home gardening, nutrition, and income-generation.
The literacy programme provides education to women and
girl children between the ages of 14 and 35. In order to make
literacy more functional and meaningful, the courses include
such elements as family health and sanitation, food and
nutrition, home economics, and civic rights and responsibilities.
The home gardening programme teaches women to grow
their own vegetables and to use herbs for medicinal purposes.
Small income-generation projects include skill-training in dress
making and sewing.
The rehabilitation of street children and women in
Colombo and Kandy is another major activity of the
organization. Named Borella Centre, this programme provides
various facilities, including a pre-school day-care centre,
vocational training in sewing, carpentry, and welding. SWM
also runs a rehabilitation centre for young women. It oversees
several gender-sensitization programmes, aimed at the
harmonious integration of women and men in grass-roots
community development efforts.
Currently, SWM projects cover 64 villages in Sri Lanka, in
which over 2,000 members participate in programmes aimed
at empowering women and making them full partners in
community life.
NEPAL
5.21
Small Farmer Development Programme
Agriculture contributes more than half of the national income
of Nepal. Subsistence farming is a way of life, but availability
of credit to subsistence farmers has remained limited. In 1975,
the Agricultural Development Bank of Nepal set up a Small
Farmer Development Programme (SFDP) to provide credit
services to subsistence farmers.
The SFDP organized small farmers and landless labourers
in small, homogenous groups of five to fifteen members in
order to reduce their transaction costs and improve their
bargaining pow-er. The principle of joint liability was
established so that credit was made available without collateral,
and peer pressure ensured its proper use and repayment.
The SFDP has expanded rapidly in the last twenty years.
By 1992, the programme covered 140,000 households in 575
villages. Besides provision of credit, over 9,000 hectares of land
have been brought under irrigation. The cost of irrigating one
hectare was only Rs 8,000 through this programme, whereas
the cost was as high as Rs 100,000 in a similar government-run
project. During the same period, literacy rates in the programme
area increased from 59 to 76 per cent for males and from 15 to
18 per cent for females. The proportion of families using
contraceptives increased from 24 to 30 per cent. A great deal of
infrastructure was also created, ranging from water supply
schemes to construction of much-needed bridges.
The impact of SFDP on the income of poor households
has been highly encouraging. The human development
indicators of families covered by the programme have shown a
dramatic improvement. This experience demonstrates that when
even a conventional bank (ADBN) sets aside a small proportion
(only 7 per cent) of its total resources to help the poor and
needy, it can achieve spectacular results by organizing the self
help efforts of the entire community.
5.22
BHUTAN
Monger district health project
Mongar is one of the twenty districts in Bhutan. An integrated
project to provide health services was launched in 1984 in the
Mongar district with the involvement of the local community.
Besides extending primary health care, it also ensured access to
referral health services and other measures to improve the health
of the local communities.
The contribution of the community included the provision
of labour and locally available materials, construction of
Development by the People
103
Civil Society Initiatives
latrines, outreach clinics, drinking water supply schemes, as
well as transportation of the materials provided by the World
Food Programme (WFP) and other agencies. Within four years
of project implementation, the Mongar district achieved full
coverage of primary’ health care, with 94 per cent of households
having and using latrines and two-thirds of households having
access to piped water. The infant mortality rate was halved
between 19S4 and 1991, as child immunization coverage
increased to 90 per cent.
The key lesson from the Mongar district health project is
the same as from many’ other grass-roots efforts: local
communities must themselves participate in designing and
implementing the projects which are intended to benefit them.
Bhutan is now extending this lesson to other districts.
MALDIVES
5.23
Integrated Atolls Development Project (IADP)
In 19SS, the government of the Maldives launched the
Integrated Atolls Development Project (IDAP) to encourage
1C4
Hitman Development in South Asia 1997
community participation in social development. This
programme aims at enabling the nineteen atoll communities
to identify their own development needs, to formulate plans,
and to implement programmes which would respond to those
community needs which have been identified by poor people
themselves.
Besides the provision of social services, the programme
also encourages income-generating activities and provides credit
for the development of the entrepreneurial talent in the local
communities.
One of the refreshing features of IADP is the
encouragement of the contribution of women in local
development. Women are fully’ represented in all decision
making forums and every project that is designed is
reviewed from the perspective of accelerating wom^
development.
This project is still in an evolutionary stage. During its
brief existence, it has already demonstrated that the government
and local communities can collaborate in an efficient and costeffective manner.
C
v« ti re I /s , , jff
WHO/ARA/98.2
Original: English
Distr Limited
WORLD HEALTH ORGANIZATION
FINAL REPORT OF
MEETING ON POLICY-ORIENTED MONITORING
OF EQUITY IN HEALTH AND HEALTH CARE
Geneva, 29 September - 3 October 1997
Organized together with the
Council for International Organizations of Medical Sciences
and the NGO Forum for Health
TABLE OF CONTENTS
Executive Summary
i-iii
Introduction
2
Keynote Speech
3
Fundamental Conceptual Issues: Discussion Highlights
The concept of equity
Equity and determinants of health
Equity in health care
Equity and globalization
4
4
4
5
5
Sharing Experiences of Monitoring Equity
Monitoring of Equity at the district and local levels - four examples
Using existing data sources to assess equity in developing countries
Challenges in monitoring equity in industrialized countries
Experiences with measuring poverty and identifying those in greatest need
6
6
7
8
10
Recommendations for Equity Targets and Indicators
Setting the framework: equity targets and criteria for selecting indicators
Recommended indicators in four essential categories:
-Determinants of health
-Health status
-Health care resource allocation
-Health care utilization
11
11
14
14
14
'5
16
Towards the 21st Century: Equity in the Renewal of
“Health For AH” Strategy
17
Advancing Equity: Strategies for WHO
Obstacles to be overcome
Focusing on solutions
Recommendations for future WHO efforts
19
19
70
21
Concluding Comments
73
Annexes
Annex 1:
Annex 2:
Annex 3:
Annex 4:
Programme of Work
List of Participants
“Global Health Chart”
References
74
70
executive summary
The challenge of promoting equity in health and health care is the major theme of the
Equity Initiative launched by the World Health Organisation and Sida in 1995. One of the
strategies adopted in focusing on equity has been the development of indicators to monitor equity,
with an emphasis on using these data to influence the policy process.
To further advance this work, the Meeting on Policy-Oriented Monitoring ofEquity in
Health and Health Care was convened from 29 September to 3 October 1997 at WHO
headquarters in Geneva. It was co-organized by WHO, the Council for International
Organizations of Medical Sciences (CIOMS) and the Non-Governmental Forum for Health.
Participants represented Ministries of Health, universities, research institutions, non-governmental
organizations, donors and WHO regional and country offices.
This technical meeting was designed to assist WHO in developing the next steps forward
in this major initiative focused on achieving greater equity in health and health care. Although the
primary concern of the meeting was policy-oriented monitoring, it was intended that this be seen
in the context of the broader range of activities proposed by the initiative including policy
development, implementation and advocacy but also be seen in relation to WHO’s new policy
Health for all in the 21st Century.
The meeting acknowledged that a precise definition of equity is not available. However
there was agreement that health inequities exist when there are inequalities in health status, risk
factors, or health service utilisation between individuals or groups, that are unnecessary, avoidable
and unfair. Equity in health requires equity in the distribution of the determinants of health
including, but not limited to, health services. Even in relatively affluent nations that emphasize
equity in access to services, there are significant inequalities in health status that reflect more
fundamental social inequalities in socioeconomic status, education, working and living conditions.
Reducing inequalities in health status to the point where we can judge them unavoidable
and fair, would therefore require: (1) special steps in the health sector to compensate for
inequalities in risk factors that arise from other inequalities (socioeconomic, gender etc.) and.(2)
further efforts to reduce these other inequalities through intersectoral action.
Inequity is a problem in all regions and all countries. Socioeconomic inequalities are the
most important determinants of avoidable inequalities in health status, with health care services
playing a lesser role. Presentations showed that there is a need for disaggregated data at all levels
to allow for the identification of inequities and that both the quality and practical use of existing
data should be markedly increased. The use of routine data from the health sector needs to be
supplemented with additional routine information from other sectors, e.g. the census or routine
household surveys conducted by labour, commerce, agriculture, social welfare or other sectors,
in order to identify neglected groups. The most disadvantaged are not a homogenous group of
society; there are significant differences between, e.g. the “moderately poor” and the extremely
poor or poorest. Measures of deprivation should be sensitive to these socioeconomic differences
with health consequences. Policy makers need to be able to be effective advocates for greater
equity, even when evidence of short-term overall economic gain is lacking.
Four key criteria for selecting indicators for monitoring equity in health and health care
v/ere recommended: Relevance to policy on equity_in any relevant sector; accessibility of
disaggregated data; simplicity; and meeting standard scientific and ethical criteria.
Different ways of formulating an equity target with a given indicator were discussed.
Formulating an equity target is probably more important than which specific indicator is selected,
as it is the target that is explicit about comparisons among the more and less advantaged. Using
cmid mortality rates, the following examples illustrate what is meant by an equity target, as
contrasted with a generic target that does not address issues of equity:
*
A generic target: By the year, reduce child mortality to x%.
•
Contrasted with possible equity targets, e.g.:
..
By the year
" , reduce child mortality to x% overall, and reduce the disparities in
child mortality between the highest and lowest income quintiles by z%; or
?
By the year, reduce child stunting to x% overall, and reduce the disparity in
stunting rates between girls and boys by y%.
-
.
• •
••
• • ■
'_
. ***. ' ’
j 77
•
•
x he recommended indicators are summarized in the table below:
Table: Key indicators for monitoring equity in health and health care
Indicator categories
Indicators measuring differences between population
groups
1: Health determinants indicators:
Prevalence and level of poverty
Educational levels
Adequate sanitation and safe water coverage
2: Health status indicators:
Under 5-ycar child mortality rate
Prevalence of child stunting
Recommended additional indicators: Maternal mortality
. ratio; life expectancy at birth; incidcnce/prevalcncc of
relevant infectious diseases; infant mortality rate and 1-4 year
old mortality rate expressed separately
3: Health care resource allocation
indicators:
Per capita distribution of qualified personnel in selected
categories.
Per capita distribution of service facilities at primary,
secondary, tertiary and quaternary levels.
Per capita distribution of total health expenditures on
personnel and supplies, as well as facilities.
4: Health care utilization
indicators:
Immunisation coverage
Antenatal coverage
% of births attended by a qualified attendant
Current use of contraception
ii
In relation to WHO’s new policy Health for All in the 21st Century, it was emphasized
that health for ail is equity. Equity is a core value of the new policy and the policy introduces
equity-oriented indicators, in particular, child health and child growth. In order to achieve equity
it should be made an explicit criterion for priority-setting. Health systems have to act and ensure
universal access to adequate quality care and adopt life-span approaches which give priorities to
prevention and health promotion.
The meeting identified a range of obstacles to equity, e.g. lack of clarity of the concept,
lack of awareness among policy-makers, lack of data, lack of analysis of existing data,
management of the health sector, general acceptance of inequities and global issues such as the
role of private companies. Strategies for overcoming these obstacles and advance equity were
recommended.
WHO needs to be bolder, and speak out on controversial issues such as privatization,
unhealthy industries, unhealthy trades and unhealthy business practices. Progress on equity will
not be achieved by a "business as usual" approach. WHO should disseminate evidence of where
pursuing economic growth without a systematic and explicit focus on equity may increase
inequity.
Among its highest priorities WHO should intensify its work to get equity higher up on the
agendas of international organizations, governments, donors, and professional organizations. The
capacity of governments to routinely monitor equity in health and health care need to be
strengthened through suggesting options for simple yet valid approaches to ongoing policyoriented monitoring of equity, using existing data sources from all relevant sectors and simple
methods of analysis and presentation. Vital statistics capacity should be strengthened by
incorporating socio-economic and geographic information as well as improving data quality, using
census data in health equity assessments and population-based data from other key sectors.
WHO should reorientate itself to equity, and to the intersectoral cooperation required to
achieve it. The Task Force on Equity in Health and Health Care should look into WHO
programmes and the extent of their equity concerns. The Task Force should expand its
membership to other international organizations, e.g. ELO, UNICEF, UNESCO. Similar
mechanisms need to be established at regional and country levels.
iii
, .
_
.
A-
™ .nd/
'.0 Jur .n.
-
2?;;’
k On •UZ.
*
V&
Reprinted from ANNALS OF INTERNAL MEDICINE Vol. 129; No. 9, 1 November 1998
Printed in U.S.A. .
MEDICINE AND PUBLIC ISSUES
Poverty and Ill Health: Physicians Can, and Should,
Make a Difference
Michael McCally, MD, PhD; Andrew Haines, MD; Oliver Fein, MD; Whitney Addington, MD;
Robert S. Lawrence, MD; and Christine K. Cassel, MD
A growing body of research confirms the existence of a
powerful connection between socioeconomic status and
health. This research has implications for both clinical prac
tice and public policy and deserves to be more widely
understood by physicians. Absolute poverty, which implies
a lack of resources deemed necessary for survival, is selfevidently associated with poor health, particularly in less
developed countries. Over the past two decades, economic
decline or stagnation has reduced the incomes of 1.6 bil
lion people. Strong evidence now indicates that relative
poverty, which is defined in relation to the average re
sources available in a society, is also a major determinant
of health in industrialized countries. For example, persons
in U.S. states with income distributions that are more
equitable have longer life expectancies than persons in less
egalitarian states.
There are numerous possible approaches to improving
the health of poor populations. The most essential task is
to ensure the satisfaction of basic human needs: shelter,
clean air, safe drinking water, and adequate nutrition.
Other approaches include reducing barriers to the adop
tion of healthier modes of living and improving access to
appropriate and effective health and social services. Physi
cians as clinicians, educators, research scientists, and advo
cates for policy change can contribute to all of these
approaches. Physicians and other health professionals
should understand poverty and its effects on health and
should endeavor to influence policymakers nationally and
internationally to reduce the burden of ill health that is a
consequence of poverty.
Ann Invm Med. 1998:129:726-733.
From Mount Sinai School of Medicine and Cornell University
Medical College. New York. New York; Royal Free and Univer
sity College Schools of Medicine, London, United Kingdom;
Rush School of Medicine, Chicago, Illinois; and Johns Hopkins
School of Public Health, Baltimore, Maryland. Fur current au
thor addresses, see end of text.
726
overty and social inequalities may be the most
important determinants of poor health world
wide. Socioeconomic differences in health status ex
ist even in industrialized countries where access to
modem health care is widespread (1). In this paper,
we make a formal argument for physician concern
and action about poverty based on the following
assertions. Physicians have a professional .and a
moral responsibility to care for the sick and to
prevent suffering. Poverty is a significant threat to
the health of both individual persons and popula
tions; thus, physicians have a social responsibility to
take action against poverty and its consequences for
health. Physicians can help improve population
health by addressing poverty in their roles as clini
cians, educators, research scientists, and participants
in policymaking.
P
Concepts of Poverty and Health
Poverty is a multidimensional phenomenon that
can be defined in both economic and social terms.
Am economic measure of poverty identifies an in
come sufficient to provide a minimum level of con
sumption of goods and services. A sociologic mea
sure of poverty is concerned not with consumption
but with social participation (2). Poverty leads to a
person’s exclusion from the mainstream way of life
and activities in a society (3). There is a difference
between absolute poverty, which implies a lack of
resources deemed necessary for survival in a given
society, and relative poverty, which is defined in
relation to the average resources available in a so
ciety. Economic measures are easy to obtain, but
social measures may provide a better understanding
of the causes and consequences of poverty. Steps
have been taken toward the development of indices
of deprivation, which have promising uses in health
services and public health research (4).
In 1978, the World Health Organization (WHO),
in the Alma-Ata Declaration, spelled out the depen
dence of human health (defined broadly) on social
and economic development and noted that ade
quate living conditions are necessary for health (5).
Despite their knowledge of this, governments and
major development organizations have largely con-
C 1998 American College of Physicians-American Society of Internal Medicine
I
tion, for example, but also through their roles in
economic development. For instance, they supply
forest resources and biomass fuels and serve as
habitats for the vectors of disease (9). Sustainability
is produced by using resources in ways that meet
the needs of current populations without compro
mising the ability of future generations to meet
their own needs (10) and is predicated on the need ■
to ensure a more equitable sharing of today’s re
sources. Meeting the needs of the world’s poor im
plies limitation of the current use of resources by
industrialized nations.
Barriers to the benefits of development include
Poverty Causes Death and Illness on a
rapid population growth, environmental degrada
Massive Scale
tion, and the unequal distribution of resources. At
one extreme, traditional, preindustrial societies are
During the second half of the 1980s, the number
characterized by relatively high birth rates coupled
of persons in the world who were living in extreme
with high death rates attributable to acute infectious
poverty increased. Currently, extreme poverty af
diseases and the hazards of childbearing; this leads
flicts more than 20% of the world’s population. A
to slow population growth. At the other extreme, inA
recent report from WHO points out that up to^Sv.t-.ra
the most developed countries, population stabilir^^
of children in the deyelosing.. wprid^ZSO.^nuIIio^.
^as
occurred. In the intermediate situation, in less
. chiidrenr^-have lowi height ;1fpf/tn^intage:Jhnd''th'ati
developed countries, population stability has not
about 50 million children have low weight for their
been reached, and the global population thus con
height (7). Micronutrient malnutrition (deficiencies
tinues to increase. In some less developed countries,
of vitamin A, iodine, and iron) affects about 2 bil
a “demographic trap" exists in which the develop
lion persons worldwide.
ment of resources cannot keep pace with the re
It has been estimated thatlrdevcfoping'counfriEs'
quirements of the growing population and poverty is
enjoyed.the?same health:,and' social conditions as the
worsened (11). The most developed countries es
most'developed nations/the currerit.'a'nnual toll of
cape the trap by buying additional essential re
more than'T'2.' million “deaths. ;in 'children'" younger
sources in the global marketplace to make up the
than. 5 years of age could’be reduced to less than
difference.
400'000.'''Anu-average-; person intone, of the Jeast f
Environmental degradation exaggerates the im
developed countries"'fias a ' life cxpectnncyij'- of ,,43' ft?
balance between population and resources, in
years;' the''life 'expectancy ■ of an average person in
one of the most developed countries,is'78 years (7)."^ creases the costs of development, and increases the
extent and severity of poverty. For example, the
This is not to deny that real gains in health have
need for fuel wood, timber for export, and farmland
occurred in recent decades. For example, since
results in deforestation, which increases soil erosion^^
1950, life expectancy at birth in several developing
flooding, and mud slides and reduces agricultural
countries has increased from 40 to more than 60
productivity. As a result, biological diversity is lost,
years. Similarly, worldwide, mortality rates for chil
production becomes increasingly reliant on pesti
dren younger than 5 years of age decreased from
cides and fertilizers, and use of expensive fossil fuels
280 to 106 per 1000, on average. Some countries
increases. Water is a critical resource. In Punjab,
show much sharper declines (7), but indices of
the breadbasket of India, the major aquifer is de
health in these countries still fall far short of those
creasing at a rate of 20 cm per year, threatening
in wealthier nations.
health by reducing agricultural productivity and the
supply of clean water (12). Economic development
without regard to long-term environmental and social
Poverty and Sustainable Development
consequences also threatens sustainability by dam
The relation between poverty and health is com
aging the systems that sustain healthy communities.
plex, and we believe that it is best understood in the
framework of a new notion of “ecosystem health,”
which places poverty and health in the nexus of
Inequalities in Health Are Socially
environment, development, and population growth
Determined
(8). Ecosystems provide the fundamental underpin
ning for public health in both developed and less
Tne strong and pervasive relation between an
developed countries, not only through food producindividual person s place in the structure of a socitinned to view health narrowly as a responsibility of
the medical sector, outside the scope of economic
development efforts. Consequently, governments have
encouraged many large-scale but narrowly focused
economic development efforts, ignoring the connec
tion between poverty and health (6). In developed
countries, governments promote various practices,
such as heavy pesticide applications, that are de
signed to increase economic development and com
petitiveness but that are environmentally unsound
and personally unhealthy.
1 November 1998 • Annals of Internal Medicine • Volume 129
- Number 9
727
180
Figure 1. Comparison of standardized mortality ratios for men 15 to 64 years of age by social class over five decades in England and Wales.
igures have been adjusted to the-classification of occupations used in 1951. Information on men 20 to 64 years of age in Great Britain was obtained from
Black and colleagues (18).
^^and his or her health status has been clearlvAiplasnia7cEdIesler6i'31'evels')t;expiainn6nly;:abbut725% '''
<h„u,n in
nnnH„n,.H
shown in research conducted over the past 30 years
(13-16). In 1973, Kitagawa and Hauser (17) published
convincing evidence of an increase in the differen
tial mortality rates according to socioeconomic level
in the United States between 1930 and I960. Thev
found that rates of death from most major causes
was higher for persons in lower social classes. In Brit
ain. research into health inequalities was summa
rized in 1980 in The Black Report (18), which was
updated in 1992 (19) and is currently under review
by an official working group. The report was pre
pared by a labor government-appointed research
working group chaired by Sir Douglas Black, for
merly Chief Scientist at the Department of Health
and. at the time. President of the Royal Collette of
Phvsicians. The Black Report concluded that "there
ai^.iarked inequalities in health between the social
classes in Britain” (Figure 1). Marmot and col
leagues. in the well-known Whitehall studies of Brit
ish civil servants begun in 1967, showed that mor
tality rates are three times greater for the lowest
employment grades (porters) than for the highest
grades (administrators) and that no improvement
occurred between 1968 and 1988 (20-22).
Such findings could, in theory, be due to differences
in age, smoking, nutrition, types of employment,
accident rates, or living conditions, but the White
hall study participants were from a relatively homo
geneous population of office-based civil servants in
London. They had largely stable, sedentary jobs and
access to comprehensive health care. A second ob
servation of the Whitehall investigations, confirmed
by the Multiple Risk Factor Intervention Trial
(MRFIT) studies in the United States, is that con
ventional risk factors (smoking, obesity, low levels
of physical activity, high blood pressure, and high
728
t
'persons^df-different'incotnSs (Figure 2) (23, 24).
An equally striking finding is Wilkinson's obser
vations of the relation between income distribution
and mortality (25, 26). Wilkinson assembled two
sets of observations. First, he found no clear rela
tion between income or wealth and health when
comparisons were drawn between countries (for ex
ample, there is no relation between per capita gross
domestic product and life expectancy at birth in
comparisons between developed countries at similar
levels of industrialization). But Wilkinson also showed
a strong relation between income inequality and
mortality within countries, a relation that has been
confirmed more recently (27, 28). The countries
with the longest life expectancy are not necessarily
the wealthiest but rather are those with the smallest
spread of incomes and the smallest proportion of
the population living in relative poverty. These
countries (such as Sweden) generally have a longer
life expectancy at a given level of economic devel
opment than less equitable nations (such as the
United States).
Recent analysis of .UfSl' data supports earlier ob
servations that, the distribution of wealth within so
cieties is associated.with,all-jcause mortality and sug
gests that the relative socioeconomic position of the
individual in U.S. society may be associated with
health. Populations in U.S. states with income dis
tributions that are more equitable have longer life
expectancies than do those in less egalitarian states,
even when average per capita income is taken into
account (27, 28). Authors of the studies that re
vealed these findings recently introduced the notion
of “social capital.” which is defined as civic engage
ment and levels of mutual trust among community
1 November 1998 • Annals oj Internal Medicine • Volume 129
• Number 9
members, as an important variable intervening be
tween income inequality and health status (29).
Evans and associates (15) suggest that one’s control
of the work environment is an important connection
between social and occupational class and morality.
The Robin Hood index, also known as the Pietra
ratio, is used to estimate the percentage of total
income that would have to be transferred from
groups above the mean to groups below the mean
to equalize income distribution. A higher Robin
Hood index value represents greater disparity in
incomes. The strong correlation between income
distribution and mortality rates shows that income
disparity, in addition to absolute income level, is a
powerful indicator of overall mortality (Figure 3) (27).
inequalities in Income and Health
Are Worsening
Many of the improvements in life expectancy and
infant mortality rates that have occurred around the
world are overshadowed by the countervailing influ
ence of increasing disparities between rich and poor.
Since 1980, economic decline or stagnation has af
fected 100 countries, reducing the incomes of 1.6 bil-'
lion persons (19). Between 1990 and 1993, the average
income decreased by 20% or more in 21 countries,
particularly countries in eastern Europe and the
countries of the former Soviet Union (30). The net
worth of the world’s 358 richest persons is equal to
the combined income of the poorest 45% of the
world’s population: 2.3 billion persons. Between
1960 and 1991, the ratio of the global income of the
richest 20% of the world’s population relative: to the
poorest'20% increased from 30:1 to 61:1 (30, 31).
Many recent improvements in population health
have been threatened and, in some cases, reversed
at the same time that income differentials have wid
ened. For example, the proportion of underweight
children in Africa may decrease from 26% in 1990
to 25% in 2005, but the total number of under
weight children is projected to increase from 31.6
million to 39.2 million because of population growth.
In the United States and the United Kingdom,
income distribution has become more unequal. Ac
cording to the United Nations Development Pro
gramme, income distributions within each of these
countries are now among the most unequal distri-
Income, 1980 U.S. dollars
Figure 2.
tjnn nnn
™pn in the United States. Data obtained from Smith and colleagues (23).
income and age-adjusted mortality rates among 300 000 white men in tne unneu w
3
__
___ ■—
•
■..........
•-
■
,...’5
•»**-
1 November 1998 ^Annals of Internal Medicine • Volume 129
’
■ ■/
•
,. ...
f" -muloV ■ W’:."'
• Number 9 ^729
butions in the world’s industrialized countries (31,
32). For example, in the United Kingdom, the pref
portion of persons with an income less than half of
the national average increased from Ifess than. 10%.-;
in 1982 to more than 20% in 1993, and unskilled,
Guatemala when incomp is earned by the father
than when it is earned by the mother because the
mother is more likely to spend the money on es
sentials for the family (30).
An important, possibly unique, randomized trial
men, in. Scotland now have a mortality1'bate:','three
in Gary, Indiana, suggests that increasing the in
times'tHat of professional men (33). This represents
come of poor expectant mothers receiving welfare
a widening from a twofold differential in the early
increased the birthweight of their babies (38). Edu
1970s. In the United Kingdom, the difference in
cation, particularly for mothers, has dramatically af
mortality rates between rich and poor has increased
fected health. In; Peru;,for.,-instance, the children of
because mortality rates have decreased faster ^mothers with 7 or -more,’.years of: education have a
among the rich than among the poor (34), aqdrffie '!’(J^li^on.,1in.,c^ftmo^^a^&J5% pom■ proportioniof'children below thb'pfficial poverty line
Spared with the children of mothers with no school
has^tripled^in1 the_^ast''ip
ing. Studies in several countries have shown that
.■ .USi’ted’l.S'catesi/ihetyt^ity; m;.incbme''ihcfdased1 irii'hll^
mothers who have completed secondary or higher
(states: Except Alaska between 168pj.'ghci''1990/ (37)education are much more likely to treat childhood
diarrhea appropriately with oral rehydration ther
apy. Families are also likely to be smaller when
Effective Interventions Reduce III Health
women are more educated (30).
Due to Poverty
A recent systematic review of the effectiveness of
health
service interventions, predominantly in indus
Some evidence suggests that improving the in
trialized countries, to reduce poverty-related ine
come of the poorest persons improves health in
qualities in health suggest^^jjj^n^armenstojpf
both developed and less developed countries. Inter
national data have been used to show that the.xiotri-'f? interventions that may bet^gddpsSW- 1 /though they
1 bling-of"pen'capitat'jfacome-^adjusf’cclLfq^pugchasi'ng f do not directly affect income
(39).
. ______
prtjgqims; ttiatitarget .high-risk; gf6jups;';outfcacti'’pro- ?
power, parity); frpm^SipOO;: using ll98Q;.^gurcs,',.'<i'6n7
responds to ah increase of .1J.' years; in Life, expect?
ancy.1 The relation Hattens off above an average per
capita income of approximately $5000 (Figure 4)
(30). The distribution of income within households
also influences health/ It; tips';'beehi; suggested; for
example.'ttiatyintakes.'10 times' imdre spending, to
achieve' ^'given improvement'in,:.child, nutrition in
grams that include home visits; and programs that
overcome barriers to the use of services by provid
ing transportation or convenient access and by using
prompts and reminderer;Largej^e^o^multidisciplinary
interventions ta^aLviriS^T^ge-r^fagerjcies' and'-' pro-
gfgihs'j nady/berajs^glsti^
a mentaEFQqd'.Pro^aS/foii^qroSiii^jits and Chil-'
Figure 3. Age-adjusted mortality in the United States in 1990 and the Robin Hood index of income inequality. Circles represent the states of
T.e Ur.tteo States. Data were not available for Nev/ Mexico. Rhode island, and Virginia. Adapted from Kennedy and colleagues (27] with permiss.cn
730
1 November 1998 • Annals of Internal Medicine • Volume 129
• Number 9
90.0
GNP per Capita in 1970 and 1995, 1990 U.S. Dollars
Figure 4.
Life expectancy at birth and gross national product (GNP} in 1970 mH iqqc in ..i-k
represent hie expectancy ,n 1970. d.arnonds represent life expectancy .n 1995. Data opened from World DevelopmenUnU.^ouWorld
dren (W1C) was initiated in 1972 in the United
States and provides healthy food, education about
nutrition, and health services to low-income women
and their children. Data analysis suggests substantial
reductions in the number of babies with low and very
low birth weights as a result (40). The project paid
for itself through equivalent savings in medical care.
^Project Head Start provides preschool; children.and
disease and reduce mortality rates, a responsibility
that arises from their knowledge of medicine and
medical practice (43). The physician-patient relation
ship is a fiduciary one, based on the inherent re
sponsibility of physicians to deserve the trust of
patients. Professionalism also extends this relation
ship to society, which confers on the profession
/ respect and certain kinds of autonomy and author
their families with education; health'-care, and social,, ity. In the context of the physician-society relation
services. Short-, and long-term benefit's have been
ship. the physician’s fiduciary responsibility takes
shown in health, developmental, and social out
the form of concern for the public health. Most
comes (41).
major traditions of medical ethics suggest that phy
Economic analysis confirms that primary care in
sicians have a special responsibility for the care of
terventions, including measures designed to reduce
poor persons, defined as those who cannot afford to
childhood malnutrition, improve immunization against
pay for treatment (44).
childhood diseases, provide chemotherapy against
In addition, physician responsibilities in patient
tuberculosis, provide condoms and education to com
care extend to the social context of health and
bat the spread of HIV, and reduce smoking (including
disease. Physicians regularly attempt to influence
consumer taxes on tobacco) are cost-effective (42).
both patients’ lifestyles and their environments to
Physicians Have Special Responsibilities
It is widely accepted that physicians have a spe
cial and central professional responsibility to treat
help prevent illness. They do so because illness is
often precipitated by behavioral and social factors.
Physicians in practice have an obligation to act on
behalf of the general public welfare (for example,
by reporting infectious diseases to the proper au
thorities). Recently, it has become widely accepted
1 November 199S • A. naZr of Internal Medicine • Volume 129
• Number 9
731
that physicians should work to promote smoking
cessation, encourage use of seatbelts, and prevent
firearm injury. Health hazards should not be ruled
out as medical concerns because their remedy re
quires social or political action. Although the
proper form and extent of political involvement for
physicians may at times be controversial, concern
for the health of the public has been an important
responsibility of the medical profession at least
since the Industrial Revolution (45).
It may be argued that although physicians have a
responsibility to care for persons who are ill even
though they are poor and cannot pay, medicine has
no particular responsibility with respect to the gen
eral condition of poverty. Physicians’ efforts to mit
igate. poverty may be seen as going beyond the
bounds of the patient-physician relationship. How
ever, efforts against poverty may have parallels in
^videly accepted attempts by physicians to prevent
Thild abuse or health hazards in the workplace.
Although patients may not ask to be protected from
toxins or abuse, physicians have agreed that they
have a responsibility to assist patients who may be
in danger and, when possible, to prevent harm. If
poverty is connected to ill health in a direct and
powerful way. it cun be argued that physicians have
sonic degree of responsibility for addressing poverty
itself to the best of their ability.
Physicians Can Help Mitigate the Health
Inequalities Caused by Poverty
A panel convened by the King's Fund of London
recently proposed four types of interventions to cor
net health inequalities related to poverty: address
ing social and economic factors; reducing barriers to
the adoption of healthier ways of living; improving
the physical environment; and improving access to
appropriate, effective health and social services (46).
Physicians have clear roles to play in each of these
efforts.
Physicians can address social and economic fac
tors both on the level of the individual patient and
on the level of the community. By being aware of
socioeconomic factors, such as insurance status, ed
ucational background, occupational history, housing
conditions, and social isolation, physicians can make
more comprehensive diagnoses and tailor therapies
so patients’ needs. Unfortunately, in residency train
ing, the social history (if it is taken at all) is often
labeled “noncontributory.” Raik and colleagues (47)
examined the content of resident case presentations
on inpatient rounds and found remarkably low rates
of mention of socioeconomic factors. Physicians as
teachers can address these factors on rounds and in
732
describing their own patients to trainees and col
leagues.
On the community level, physicians can advocate
for public policies to improve the health of the
disadvantaged. Jarman (48) showed that physicians
know that it is more complicated and takes more
time to care for poor patients than for patients who
are not poor. With this evidence, he was able to
persuade the National Health Service in the United
Kingdom to take patient economic status into ac
count in rewarding general practitioners who work
in deprived areas. Given the growth of managed
care in the United States, physicians should be at
the forefront of those calling for poverty-based risk
adjustments to capitated payments.
As research scientists, physicians can advance the
understanding of the mechanisms by which depriva
tion leads to ill health and the development of more
effective interventions to reduce inequality in health
(49). Similarly, physicians who are aware of the
adverse effects of international debt on health can
urge debt relief for the poorest countries (50).
Physicians may also be able to assist in removing
barriers to healthy lifestyles—for example, cam
paigning against the promotion of tobacco, which is
increasingly being targeted to adolescents in less
developed countries and in minority communities in
the United States (51).
Physicians can affect environmental factors asso
ciated with poverty by advocating for legislation to
maintain and improve the quality of air. drinking
water, and food. Physician-lcd public health efforts
in the United States have been instrumental in re
ducing the incidence of lead poisoning, which is
strongly associated with poverty. Internationally,
physicians are participating in local initiatives sur
rounding Agenda 21, developed at the 1992 Earth
Summit in Rio de Janeiro, Brazil. More than 1300
local communities in 31 countries have developed
their own action plans, manv of which feature
health issues. Through the WHO Healthy Cities
Project, cities have.addressed such issues as smok
ing, sanitation, air pollution, and socioeconomic dif
ferences in health (52).
Approaches to improving access to effective
health and social services in the United States and
elsewhere have been extensively reviewed (39, 53).
However, more than 800 million persons lack access
to health services worldwide, and the increasing im
position of user fees (copayments and deductibles)
in many countries has exacerbated inequities in care
(54). Physicians and their associations should lead the
movement for universal access to health care (55).
An international meeting on health and poverty
hosted by WHO and Action in International Med
icine (which has approximately 100 affiliated orga
nizations in more than 30 countries) urged associa
1 November 1998 • Annals of Internal Medicine • Volume 129
• Number 9
tions of health professionals to engage in activities
to reduce health inequalities due to poverty (56).
Dr. Gro Harlem Brundtland, the newly appointed
Director General of WHO, has indicated that she
intends to make the reduction of ill health due to
poverty a priority for her term of ofhce (57). The
United Nations Declaration of Human Rights in
cludes access to the basic necessities of life, such as
food and water, as well as health care. However, 50
years after the Declaration was written, we are still
far from providing this access to everyone. Physi
cians have an important role to play in helping to
transform the rhetoric of the Declaration into reality.
Kitagawa EM, Hauser PM. Differential Mortality in the United States: A Study
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Kennedy BP. Kawachi I, Prothrow-Stith D. Income distribution and mor
tality:
cross sectional ecological study of the Robin Hood index in the United
of Community and Preventive Medicine, Box 1043, Mount Sinai
States.
BMJ. 1996;312:1004-7.
School of Medicine, New York, NY 10029; e-mail, mm6@doc
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Current Author Addresses: Dr. McCally: Department of Commu
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17.
1 November 1998 • Annals of Internal Medicine • Volume 129
• Number 9
733
BMJ 1999:318:1020-1021 ( 17 April)
Editorials
Tackling health inequalities in primary care
Recording socioeconomic data in primary care is essential
Tite adverse health effects of social inequality are enormous. In the United Kingdom death rates at all ages are two
to three times higher among people in social class V than among those in social class 1.12 Poor socioeconomic status
also erodes social, psychological, and physical health." Reducing health inequalities is central to the United Kingdom
government's recently outlined health policy/ a commitment confirmed by the positive reception given to the
recently published Acheson report on inequalities in health.5 However, in spite of their importance both to the overall
health care of individuals and in health policy, socioeconomic factors are not routinely assessed in clinical practice.
The power of the socioeconomic determinants of ill health requires that we should adapt the traditional medical
model. We now understand that diseases have both biological and societal causes, yet our interventions remain
focused on the biological. ' We need to begin to take histories which routinely include the eliciting and recording of
societal risk factors, and we need to begin to use society's resources for both prevention and treatment of illness and
disease.
Deciding exactly what to ask and record will require further research. The registrar general's classification of social
classes has been used in the United Kingdom for most of this century and is currently being modified. However, it is
too cumbersome to use during a consultation, does not always provide a good measure of the socioeconomic factors
important to health. and may be inappropriate in countries other than the United Kingdom/ General practiuoners
will want to concentrate their efforts where evidence for the influence on health is strongest by finding simple, user
friendly, and non-stigmatising methods-of eliciting and recording data on material poverty, unemployment, poor
housing, and social isolation.
Factors reflecting tlic social environment and an individual's involvement within itwhich include levels of perceived
hostility, trust in others, or membership of groups within die communirymay be important determinants of hcaldi
inequalities. In addition, it is increasingly clear diat people's cumulative socioeconomic experiences over their
w hole lifetimes play a greater pan in determining hcaldi dian does dieir socioeconomic level at a single point in
time.’
Recording socioeconomic data would be useful for several reasons. Recent guidelines on preventing cardiovascular
disease emphasise die need to base management on an individual assessment of absolute risk.2 Socioeconomic status
should be an important pan of any such assessment. The approximate doubling of risk of coronary heart disease seen
in people in die poorest socioeconomic groups in comparison to diose in die richest groups is similar in size to the
increased risk produced by cigarette smoking. No one would seriously suggest that an individual's risk of coronary
heart disease could be accurately assessed without knowledge of their smoking habits. Knowledgeof socioeconomic
factors would also facilitate targeting of preventive healthcare measures such as cervical screening15-' and childhood
immunisation.1- which arc known to reach diose in poor socioeconomic circumstances less well. In addition, specific
interventions designed to reduce hcaldi inequalities require knowledge of patients' socioeconomic status if they arc to
be offered to diose people most likely to be helped.
The people registered widi general practitioners in the United Kingdom represent one of the largest, most
comprehensive, and most representative sources of epidemiological data in the world. Routinely collected
socioeconomic data would be a valuable resource for research into health inequalities and for assessing progress in
die efforts to reduce tiiese. One of die central diemes of the Acheson report was the need for high quality
comprehensive data to improve the capacity to monitor inequalities in health and to evaluate the effectiveness of
measures taken to reduce them/
Witii increasing computerisation of practices, the actual recording of socioeconomic data should be straightforward.
■Simple questions relevant to the particular patient could be asked when patients first register and opportunistically at
subsequent consultations. New computer codes for die different questions and their responses could easily be
produced.
lot about asking intrusive questions, and it would take up very
f doing what most clinicians in primary care already do, albeit
rd wav. Recent work from Norway has shown that while the
cial factors varied widely, when such factors were known they
ieople are often asked if they live alone and about social
ocial isolation, their housing situation, and other socioeconomic
rnctors. oucn imormauon may not always be recorded and hence may not be.put to the greatest usefor example, in
oenerating a referral to a community organisation or to a health visitor.
The government seems io be sincere in its wish to tackle health inequalities. For general practice to play a full pan
in translating this commitment into improved health for those most in need we will need to record accurate and -\ alid
socioeconomic information about our patients.
—-•
Liam Smeeth. Clinical lecturer.
Department of Primary Care and Population Sciences. Roval Free and University College London Medical School.
London N19 5XF (1.smeeth'?? ucl.ac uk)
Iona Heath. Ch.ur.
Health Inequalities Task Group. Royal College of General Practitioners, London SW7 1PU
1.
Office of Population Censuses and Surveys. Registrar general's decennial supplement on occupational
mortality 1979-83. In: London: HMSO , 19S6.
2. Office of Population Censuses and Surveys. Occupational mortality: childhood supplement 1979-80. 198283. In. London: HMSO , 19S8.
3. Lynch JW. Kaplan GA, Shema SJ. Cumulative impact of sustained economic hardship on physical.
cognitive, psychological, and social functioning. A' Engl J Med 1997; 337: 1889-1895.
4. Our healthier nation: a contract for health. London: Stationery Office . 1998.
5. Report ifthe independent inquiry into inequalities and health. London: Stationery Office . 1998. ..
6. Bartley M. Carpenter L. Dunnell K. Fitzpatrick R. Measuring inequalities in health: an analysis of mortality
patterns using two social classifications. Sociology ofHealth and Illness 1996: 18: 455-475.
7. Marmol M. Improvement of social environment to improve health. Lancet 1998; 352: 57-60.
8. Davey Smith G. Socioeconomic differentials. In: Kuh D. Ben-Shlomo Y. cds..4 life course approach to
chronic disease epidemiology. Oxford: Oxford University Press. 1997:242-276.
9. HHS Executive. SMAC statement on use ofstatins. In: Wciherby: Department ofHcalth . 1997(EL(97)41.)
10 Bcardou R_ Oonon J. Victor C. Evaluation of the cervical screening programme in an inner cits health
district. EMJ 1989. 299: 98-100.
11 Fleming DM. Charlton JRH. Morbidity and healthcare utilisation of children in households with one adult:
comparative observational study. 13MJ 1998; 3)6: 1572-1576.
12 Gulbrandsen P. Fugclli P. Hjondahl P General practitioners' knowledge of their patients' psvchosocial
problems multipraciicc questionnaire survey. HM.l 1997.314: 1014-10)8.
13. Gulbrandsen P. Fugclli P. Sandvik L. H jondahl P. Influence of social problems on management in general
practice mullipracticc questionnaire survey. HMJ 1998. 317: 28-32. -
15 Khoj-Bin - J Nepal Health Research Council 1997; 1(1): 15-20.
MAKING HEALTH A PUBLIC AGENDA:
BEYOND AD VOCA CY TO THE
COMMON CONCERN OF ALL.
1. INTRODUCTION
Health is a state of equilibrium
between a human's external and
internal environment. Health is an
expression of total facets of human
being. These facets are determined
by the physical, mental, psycho
social, cultural, economic, genetic,
chemical and spiritual aspects.
Health is an integral part of a
human's living shared among and
with other humans and biotic
community. Health relates to
everything that goes to constitute
the human life-style and life
system. Therefore, health must be
holistic and health care must lead to
health development and be actively
participatory. The concept of health
and health care has to transcend the
present narrow teclmo-centric and
unethical top-down prescriptive
care system.
sector managers, and other related
professionals should participate in
the process of health development
and management. Unfortunately,
the people's right to participate in
health and development is often
ignored by everybody. Their needs
are almost always compromised by
the
politicians
and
health
administrators. People are often
forgotten in the process of decision
making at the political and
management
level.
Nepal's
constitution has invested sovereign
right in the hands of people. This is
now ignored by every policy
maker.
Indira Shrestha*
Mathura P Shrestha’"
disciplines,
including
the
politicians to make health care and
health
politics
transparent,
appropriate and accountable. This
should at least do away with the
present mismatch of inefficient,
unitary, dictatorial, prescriptive,
and top-down systems that are
generating inequalities, injustices,
disparity and deprivation in health
and health care.
Health is also a precondition for
development, and a powerful
instrument in poverty reduction.
Development
and
poverty
alleviation should be inter-linked.
As
far as
development
is
It
is
our
common
social concerned, the fundamental debate
responsibility to make health a is about whether the people should
public agenda. Health is to be benefit, if at all, only from (lie spin
taken beyond the advocacy level offs of the lop-sided accumulation
and is to be the common concern of or should be allowed to participate
all. Quality of life cannot be in the development on their own.
developed without the people's Another dilemma for us is whether
participation
and
initiatives. we should have an assisting, or
Health is an integral part However, the professionals should even a colonial, attitude in making
of a human's living continue their role of advocacy to the people dependent on us as
shared among and with expand die awareness of the people providers or whether we should
other humans and biotic about their health and its have a facilitating attitude by
determinants, about themselves and empowering the people to assert
community.
their potentialities, and to motivate their health rights.
them to change and to create things The first option is the product of
Health is a basic human right and is
around them for tire development unethical,
exploitative
and
also everybody's responsibility.
of their own and every one else's domineering
thinking
which
Like any right, health is to be
health. The professionals should maintains
a
master-slave
asserted rather than given or taken.
develop such a system that the relationship in the society and
Responsibility for health policy
people are able to assess their real subjugates the people to become
development, management, and
needs and to get organized to assert mere parasites or passive receivers
advocacy should not be limited to
their health rights actively. This of the imposed choices or services.
health professionals alone. All the
obligates the providers to empower This would further widen the gaps
stake-holders
and
all
those
themselves and the users. They between those assisting and those
contributing human development
should all work together with assisted, and between the rich and
and services including the people,
people of other professions and the poor - generating more and
the politicians, inter- and intra
’ Pediatrician, Kami Children Hospital.
" Chairman, Nepal Health Research Council (NHRC).
] 6 Khoj-Bin - J Nepal Health Research Council 1997; 1( 1): 15-20..
more poor and deprived ones. This
again puts societies, communities,
nations and the world in a
permanent state of tension and
conflicts.
2. Pluralistic health care
and freedom to have an
informed choice
including Tibetan medicine and
those of other regions of China,
chiropractic and other systems of
medicine in other parts of world
should have broadened the horizon
of scientific understanding of the
health professionals. The authors
recommend NOT to dismiss even
Dhami, Jhankri and Gurau types
of faith healing (many believe them
to be the most primitive healing
practices) as practices related to
superstition. Scientific probing on
their uses and potentialities should
be encouraged. Benefits of these
practices can at least be compared
to modem "suggestive hypnosis”
and "stress-therapy” undertaken by
some “modem” psycho-therapists.
The so-called national health care
The second option is ideal but system, although quoted and
believed by many, never existed in
difficult. It may at times be even
impractical. However, if we are any country as a single entity.
really in the business of health we Health seeking behavior of the
should
break
the paradigm people of any country has always
paralysis within and around us and been diverse. Hence, the health
take a bold step ahead. Paradigm care system of any country has to
accepted
as
pluralistic.
paralysis refers to the severely be
Pluralistic
health
care
does not
restricted capacity of a person to
see the prospects or future mean the multiple service units or
potentialities in a subject or an item institutions of a category of care
beyond his/her narrow beliefs or only. It includes alternative care
systems as well.
understandings generated within
the limits of norms binding him/her
on that subject or item. Without the
Whatever the system, the people
people's concern and participation, Health seeking behavior of
should have freedom to make an
the health of the people and the
the people of any country informed decision after receiving
nations becomes unpredictable.
has always been diverse.
comprehensive information in an
Quality of life, even if improved
open and transparent atmosphere.
without the people's own initiative, In promoting modem and scientific
This
should be
within
an
becomes secondary or insignificant. medicine we have inadvertentiy
accountable system, so that nobody
Humans become passive tools of a exposed ourselves and die people
is misguided or has a false sense of
giant system under external control. to aspect blindness and some types
security. As far as the freedom of
Here, die decision making process of paradigm paralysis. Aspect
informed choice in health care of
tends to be based on whims and blindness
is
a
common recipients is concerned, the later
fancies of politicians or providers psychological condition in which
should be fully and properly
radicr tlian on objective reality. the eyes do not see, or die
informed or counseled so that they
Willi so many deprived and conscious awareness is obliterated
marginalized poor around, a nation from, die aspects in which an could take an independent decision
can not be called developed. observer is not interested or (without pressure or false promises
false
belief)
with
full
Poverty alleviation in any country ignorant. We have convenientiy or
understanding
of
the
benefits
as
should have a definite agenda and managed to phase out many
die means by which the poor can traditional systems of health care well as risks or side-effects after
have access to productive assets. without a second thought and by having used or received the item of
It is the
By productive assets, we mean that removing all possibilities for them health service.
professional
responsibility
of any
people will have both sustained and to prosper and survive. We
recurrently productive employment brandished every thing associated health professional to provide all
and be able to utilize those assets to with these traditional systems as relevant information related to
meet dieir heeds as far as a decent superstition or inferior or out of available options in the manner
and
healthy
livelihood
is date. Even within traditional understandable to the patients or
concerned.
With
a
political systems, any thing foreign or clients (or their legal wards, in case
commitment and good management related to it became superior to any of patients or clients with restricted
we may make impossible possible. thing national. Therefore, the most autonomy to make independent
decision e.g., young children,
For a good management we need to serious victims were our own
mental handicaps, etc.).
have a good policy and plan. All Nepali traditional systems. This
these are possible with an informed way, we restricted our own Providers too should be given
decision of the concerned people. understanding and our capacity to opportunity to develop, to compete,
Essential national health research, develop
our national
health and to establish their credibility in
if in-built in die health care system including national health research.
their own right with responsible
development, could provide tiiose
within
a
Ayurveda has at least a history professionalism
people options for die appropriate
and
transparent
which could amaze any modern accountable
decision.
scientist in health sciences for its system. Health professionals must
empirical approach. A big stride not let themselves be imprisoned
made recently by Acupuncture, within the cocoons of ancient or
Chinese
traditional
medicine present glory of their profession,
1/ Khoj-Bin - J Nepal Health Research Council 1997; 1(1): 15-20.
the secrecy of any kind, and any
myth. They should leam that they
are not healers by themselves but at
the service of the people to help
them in healing or in preventing
health and related problems.
Systems should compete each other
to
complement
health
and
development without wasting their
energies in plrasing each other out.
social and physical conditions of
the country and the people to have
tlie human development uplifted,
are welded to make the rich richer
and the poor poorer. Open market
is advocated by the politicians with
the promised benefit of competitive
market that would bring the price
down and raise the quality. They
also harp that it is natural to make
the market demand oriented.
3. PRIVATE-PUBLIC MIX However, this make the market
monopolized. As demand could be
Tire private-public mix is a good artificially boosted it is not always
idea if it is critically understood need or problem based. People are
coaxed
to
demand
and correctly handled. At present often
the wave of privatization is unnecessary and even harmful
deliberately fostered in order to things. Cigarette smoking is one
ease the escapist mentality of such example resulting from
unresponsive • politicians
and aggressive marketing for the profit.
decision makers including so called Just as "good money is driven out
experts and advisors. Together. of market", equity and social
they
are
evading
their justice are driven out of people's
Multinational
responsibilities towards the health livelihood.
companies
are
aggravating
this
for all. Time and again they try to
redefine primary health care in process using their economic power
order to subvert the philosophy and and global networks.
concept of Alma-Ata Declaration.
In some developed countries where
privatization is in vogue, the
question of cq'uity and social justice
in health is well taken care of with
adequate access to and distribution
of opportuiutics and resources.
efficient insurance and social
security
systems.
and
an
infrastructure developed to allow
freedom of informed choice.
There, the private sector thrives
within the limits of professional
discipline, working and transparent
legal systems and multiple but
independently viable regulatory
mechanism, informed and protected
consumerism, and accountable
governance and bureaucracy.
Each country has developed its
system according to its historical,
social and national characteristics.
In developing countries, the private
sectors are heavily preoccupied in
making profits and in importing
technology and systems rather than
developing
and
innovating
according to the conditions of their
countries.
Open market system
and privatization, instead of being
developed to suit tire historical.
divert the resources from the needy
sectors to so called development
sectors without bothering to
understand and implement the
development process itself, or to
cover up the widely prevalent
incompetence, inefficiency, and
corruption in and around them.
This is a typical example of
syndrome of backwardness. The
syndrome is widely prevalent in
Nepal
and
other developing
countries. The syndrome is the
result of deviant behavior in the
power center and is related to
opportunism
(specially
the
tendency to gain affluence by
subvert or covert means), and the
psychological
conditions
of
paradigm
paralysis,
aspect
blindness, and imitation complexes.
The term, imitation complexes,
refers to series of weaknesses that
make a person vulnerable to copy
or imitate technology or methods
without bothering to understand
how these arc originally developed
and
without
testing
their
appropriateness in relation to the
place or condition where these arc
transferred.
Aggressive marketing often
coaxed the people to
demand unnecessary and
even
harmful
things. Another question is. should we
Cigarette smoking is one classify all non-governmental
organizations (NGOs) as the
such example.
private sector? There arc some
NGOs in Nepal which arc active,
effective and popular and really arc
For a long time to come, the private not after making a profit. They arc
sectors in the developing countries campaigning to make health a
will only be able to provide viable public agenda by working hard to
alternatives in health care for those enable tlie people to assert their
who could pay high price. health rights, and by addressing tlie
However, the sector is not able, at issues of equity’ and social justice in
present, to address tine questions of health. However, there are also
equity’ and social justice in health. many
mushrooming
NGOs
The public sector has to address controlled by the same elite groups
those issues (equity’ and social in the power-center or who are
justice) along with the issue of under the tutelage of some donors
cost-benefit from
an overall or INGOs, and who are equally
perspective. Therefore, the attempt good as corrupt executives and
to compare public and private bureaucrats in the government at
sectors in developing countries can hijacking
not be justified without critical
notes or analysis.
Therefore, we have to examine all
The attempt to go private by any
means is also related to tlie sub
conscious tendency of politicians,
national executives and planners to
disown their accountability towards
the well-being of tlie people, to
aspects of this and work hard to
find and the benefits intended for
the people.test the appropriate
private-public mix in our own
historical, social, cultural, and
political perspectives. We have got
]g Khqj-Bin - J Nepal Health Research Council 1997; 1(1): 15-20.
to find our own solution to our
problems.
Private-public
mix
should have the country's own
formula. We could learn from
others and adapt well-tried systems
to our own conditions. But we
should never graft any thing to our
own system dogmatically and
uncritically.
is widely publicized and believed to The
promised
socioeconomic
be so. The dependency syndrome of development of the country and
the countries has become so serious people with tire foreign assistance
that tiiey now have only piped was never realized. The proportion
dreams and empty or unfulfilled bellow the poverty line increased.
promises for human development. The gap between the rich and the
The aid intoxication has affected poor increased out of proportion.
elite in power-centers from the The expatriates could never really
capitals down to villages. They are understand the plights and needs of
now simply tools to "assistance" the people. The donor agencies'
mentality. Instead of facilitating follow up activity on what
development by the process of happened to their assistance ended
Housing
and
financing
empowering
the
people
and with attractive and carefully
companies provide opportunity
concerned agencies or development worded evaluation reports prepared
to the people.:
units by sensitizing them to their by smart men and women in the
real needs and enabling them to take cozy cloister of executive rooms of
But at what cost?
initiatives and actions to solve these Kathmandu and other urban
| Reality |
and develop, they are consciously or centers.
subconsciously promoting slavery
If you take a loan front a Shahu with a message, ''Be dependent and The promised socioeconomic
die money lender - you have to
make others depend on you". Even
development with foreign
pay an interest of Rs. 1 per 1,000
at the community level, more and
assistance
was
never
per day which equals to 36.5 %
more people are made to believe that
realized. Foreign aid has
per annum. This makes die people
there is no way out for them and
tolerate die existing racket.
increased
the
economic
their countries without foreign
burden
of
people
by
way of
assistance. Power elite in all
The financing companies provide
heated
economy
and
you a loan at a cheaper rate of developing countries arc doing every
inflation.
tiling to consolidate tltis "make
21%.
belief' condition.
But die racket make you pay a
The foreign assistance not only
minimum of Rs. 5 per 1,000 for
Nepal
now
receives
foreign pampered and corrupted urban and
the evaluation of your properly or
elite
who
place
assistance to the tune of more than educated
collateral against which die loan is
200 million US Dollars per annum themselves in and around power
released. This naturally gives an
out of which 75 percent is in the center to ensure their interests and
opportunity for more loan amount form of loan (Based on calculation places for them on tire back of
as die evaluation team would
on the trend of foreign assistance ignorant and subjugated people, but
inflate die cost of collateral to
between 1991 - 1996). Over and increased economic burden of the
twice die actual cost. An agent
above this, an estimate of 65 to 125 people with inflation and taxes.
who negotiates die loan as a
million USD is flowing in Nepal to When money is flushed in the
"security’ man” would charge you
finance and assist hundreds of market the economics get heated up
at least 7% of the total loan
NGOs in Nepal. For the year even though the money barely
amount
1996/97, the budget is set at 1.03 trickle to the majority of people.
billion USD with a deficit of 301
5. Commercialization of
4.
Foreign
Aid,
Foreign million USD. According to Nepal
Assistance and Development. National Bank's quarterly report on health
present economic performance,
Today, a common person is more internal revenue collection is Trade and commerce is used more
convinced than ever before that die actually falling along with lower and more for unethical purposes by
developing countries are no more private sector investment and the people in power center.
independent There is -no lack of higher inflation rate of 10.1 Marketing has become more and
examples or evidences for such percent. Tltis may further increase more aggressive serving the interest
assumption. Developing countries economic burden of the people and of profiteers. Almost every thing
are now more or less addicted to dependence of the country on including biological attributes from
foreign aid. Like addicts tiiese foreign Ioan. Government and taste to sex and maternity is
countries have lost dieir capacity as NGO maclunery are increasingly commercialized. It may not be
surprising if even an individual's
well as initiative to self-reliance and made
dependent on
foreign
thinking process is commercialized.
self sustenance. The improvement in assistance.
Their
activity
is Marketing of health can not be an
services, distribution systems and increasingly fueled and tutelaged
exception. Health is now more a
living standard in developing by foreign donors.
commodity for buying and selling.
countries, although not very much,
is attributed to foreign assistance. It
19 Khoj-Bin - J Nepal Health Research Council 1997; 1(1): 15-20.
Almost even' thing including
biological attributes from
taste to sex and maternity is
commercialized. It may not
be surprising if even an
individual's thinking process
is commercialized.
Health
care
has
remained
prescriptive
even
today.
Transparency and accountability in
health care can not be imagined in
developing countries where people
are politically and socially so
disimpowered. Health is being
taken for granted as an obligation
rather than that of right or
responsibility. Governments have
deregulated those rights which the
people thought as their own.
Instead, they are actively regulating
exploitation,
disparity
and
deprivation.
7. What we could do ?
If we are in the business called
health it should be our social
responsibility to promote health
and defend health rights. First of
all, we have to redefine politics.
Politics
is
the
process
of
development of lifestyle and living
for the people and by the people.
Politics is related to every thing
determining the health of the
people and the planet. Therefore,
people specially the women should
participate in all socio-political
aspects of the locality and the
country for their health and
development. Politics can not be
and should not be left at the hands
of so called politicians. People
should
direct
and
control
politicians but not other way round.
People have to politicize health to
protect their health rights and not in
the terms of politicians nor for the
purpose of power politics or
partisan politics.
Secondly, we have to empower the
people to have informed decision.
Empowerment should include their
ability to take leadership and
initiatives in health right from
research all the way through policy
formulation,
planning
and
programming,
implementation,
supervision, monitoring, evaluation
and review.
i
Politics is the process of
development of lifestyle and
living for the people and by the
people.
Therefore,
people
specially the women should
participate in all socio-political
aspects of the locality and the
country for their health and
development;
People should
direct the politicians but not the
other, way round.
People should be made concerned
of their health, their rights and
potentiality.
In short, we must
make health a public agenda (Fig 1
and 2).
Figure 1
WHY HEALTH AND HEALTH CARE SHOULD BE ON THE
' PUBLIC AGENDA ?
'
•
HEALTH IS BOTH THE RIGHT AND RESPONSIBILITY OF PEOPLE
• •■HEALTH PROVIDERS MERELY EXERCISE THEIR PROFESSIONAL ROLES
DELEGATED BY THE PEOPLE / USERS: WITH A TRUST IN THEIR PROFESSIONAL
CAPACITY
•
PEOPLE HAVE A RIGHT TO HAVE INFORMED CHOICES -OF AVAILABLE HEALTH
iii 1 SERVICES WITH ADEQUATE KNOWLEDGE OF THE BENEFITS AND RISKS OF.USING
THEM
'
•
.
HEALTH IS DETERMINED BYEVERY,THING THAT RELATES TO HUMAN BEHAVIOR
AND LIFE-STYLE, AND THUS THE PEOPLE NEED TO PARTICIPATE IN HEALTH AND
T DEVELOPMENT IN A RESPONSIBLE WAY :
.
PUBLIC CONCERN IS THE MOST IMPORTANT FACTOR TO GET POLITICAL
COMMITMENT.FOR HEALTH
?
• . PUBLIC CONCERN WILL ADDRESS THE ISSUES OF EQUITY AND JUSTICE IN
: . HEALTH CARE BETTER. '.
■
20 Khoj-Bin - J Nspal Health Research Council 1997; 1(1): 15-20.
SOW CAN WE PUT HEALTH ON THE PUBLIC AGENDA?
•
BY EXPANDING THE KNOWLEDGE OF THE PEOPLE SO THAT THEY. ARE
CONCERNED TO COMMUNICATE, DEBATE AND PARTICIPATE IN MATTERS OF
HEALTH
•
BY MAKING THE HEALTH C.ARE SYSTEM TRANSPARENT AND COMPREHENSIVE \
• '5. BY DEVELOPING AN ACCOUNTABLE CARE SYSTEM
:
BY INVOLVING ALL' STAKE-HOLDERS INCLUDING'POLITICIANS, THOSE IN THE
MEDIA,-:NGOs; ASSOCIATIONS .AND ORGANIZATIONS, AND THE PEOPLE
IN
HEALTH CARE DEVELOPMENT
.
. .
•
BY ORGANIZING PUBLICFORA AND MASS CAMPAIGNS OR MOVEMENTS.
•
TO BE A GOOD DRESMER WE .HAVE TO
REMOVE THE BARRIERS BETWEEN POLICY
MAKERS, PROVIDERS AND PEOPLE, .'
AND '
OF THE PAST, PRESENT AND FUTURE.
EQUITY INITIATIVE
Paper No. 6
WHO/CHS/HSS/99.2
Original: English
Distr. Limited
oooooooo©©©©©©®****®
Report of
Consultation on Equity and Health in
South East Asia:
Trends, Challenges and Future
Strategies
Thimphu, Bhutan, 23-27 November 1998
OOOOOOQOOOOOOCOOOOaO
World Health Organization
Table of Contents
List of Abbreviations
.......................................................................................
1V
Executive Summary
...........................................................................................
v
Conclusions and Recommendations
..............................................................
VI
1. Introduction...................................................................................................
1
2. Sessions
2
........................................................................................................
2.1 Globalization, the Current Crisis and Impact on Equity ..........................
2
2.2 Defining and Mapping Inequities
........................................................
4
2.3 Community Participation............................................................................
5
2.4 Intersectoral Action
...............................................................................
7
2.5 Health Sector Reform...............................................................................
8
2.6 Public/Private Mix
................................................................................
9
2.7 Resource Allocation
...............................................................................
11
3. Group Reports
............................................................................................
13
3.1 Group 1:
Mapping and Monitoring Inequities.............................
13
3.2 Group II:
Influencing Equity Related Policy...............................
15
3.3 Group III:
Resource Allocation and Utilization with an
Emphasis on Equity.........................................................
16
............................................................................................
17
3.4 Group IV:
4. Concluding Session
...............................................................................
19
Annexes
Annex 1
Agenda
.........................................................................................
20
Annex 2
Field Visit to Punakha District ...................................................
22
Annex 3
List of Participants and Observers ............................................
23
iii
Executive Summary
A Consultation was held in Thimphu, Bhutan, on Equity in Health in South-East Asia:
Trends, Challenges and Strategies, from 23 to 27 November 1998. The consultation was
jointly organized by WHO/Headquarters and South-East Asia Regional Office. Tne consultation
was attended by forty participants coming from countries of the South-East Asian Region and
some from the Western Pacific Region. The purpose of the consultation was to share the
experiences of countries in identifying and mapping inequities, and in designing policy changes
to promote equity. The consultation was structured around six themes:
0
0
0
°
0
®
Globalization and its impact on equity
Mapping and monitoring inequities
Inter-sectoral actions to reduce inequities
Health sector reform
Public/private mix in health care, and
Resource allocation.-
Each of the themes formed the forum for the presentation of papers by participants and
discussions. As a result of these discussions four working groups were formed on:
•
»
•
•
Mapping and monitoring inequities
Influencing policy
Resource allocation for equity, and
Good governance for reducing inequities.
The consultation discussed the current economic crisis confronting many of the countries
of the Asian region and concluded that while the crisis had its root in the banking sector, the
banks themselves were seldom paying the price of their profligate lending while the poor who
did not benefit from these lendings were now bearing the burden of the crisis. In addition the
poor paid more of their income for health care than the rich. It is important to recognize issues
related to equity in health as a human rights issue and health sector reform must be oriented
towards an understanding of the causes that lead to systematic patterns of discrimination and
^devising ways to protect the vulnerable and the poor. The roots of inequities in health lay
principally in socio-economic disparities and hence called for holistic approaches which involved
other sectors. The recent rapid growth of the private sector has led to questioning the efficiency
and effectiveness of the public sector and an insistent call for privatization by development
agencies. However, the lack of regulation of the private sector and the absence of adequate
social security measures for protecting the poor have led to increasing inequities. The role of
governments, and that of the public sector, should be reassessed and strengthened.
The consultation felt that civil society, including appropriate NGOs and community
groups, have a key role to play in highlighting growing inequities in health and in promoting
policies to reduce them. Equity data banks could provide the necessary impetus towards action
and. academic institutions could provide the foci for collecting and synthesizing information that
uncover disparities in health status and access to heal± care.- WHO has a key role to play and the
consultation recommended a set of actions for WHO to undertake. These recommendations are
contained in the next section. Primary health care still remains the most useful approach to
provide universal health care to all peoples through a sustainable and equitable framework.
■v
Conclusions and Recommendations
WE, the participants in the Consultation on Equity in South and East Asia, having gathered in
Thimphu, Bhutan, 23-27 November 1998,
WISH to express our gratitude to the Government of Bhutan and WHO for hosting the
consultation and the extensive preparatory work performed,
CONCERNED at the growing poverty in the world and the consequent rise in inequities in health
and socioeconomic conditions, and the negative influences of globalization on the plight of the
poor,
EXHORT the countries represented in the consultation to pursue their goals of achieving
equitable and sustainable health systems,
BELIEVE that WHO must assume a key role in promoting and coordinating social action against
inequities in health,
CONCERNED that WHO’s role in addressing inequities in health could have been more
effective, we are convinced that its leadership and capacity in this area must be significantly
strengthened, and it must exert renewed efforts to promote PHC as a key approach to achieve
equity in health,
CONVINCED that its leadership in health matters among international agencies associated with
socioeconomic development must be renewed and it must establish the necessary partnership
with people and communities whose empowerment is essential to achieve equity and social
justice,
WE strongly support the new Director-General’s initiatives in reforming WHO into an efficient,
transparent and influential leading international agency, and urge WHO to take the following
actions toward reducing inequity in health:
1. To establish a cabinet project to address problems of inequity in health in all clusters of
programmes,
2. To ensure that primary health care is fully supported through a holistic sustainable approach
in keeping with local values and resources,
3. To pursue vigorously its collaboration with civil societies in countries as is being done by
other international agencies and, to this effect, make significant allocation of its budget to
support such organizations at international and country level,
4. To establish partnerships with other relevant international organizations involved with socio
economic development in order to intensify national efforts for health development.
WE further recommend that NGOs and other members of civil society' in countries form
networks to fulfil the function of health watch in countries. Such networks should also monitor
the efforts of WHO in supporting civil societies in their efforts to reduce inequities in health.
First draft circulated for comments only. Do not quote without permission. Paper presented at the
1PHN Conference at Bangalore, India, 15-18 November 1999.
Explaining Slow Progress in Human Poverty Reduction in South Asia
Binayak Sen
bsen@bdonline.com
13 November 1999
I.
Introduction
Over the last two decades South Asia has made progress in both income and non-income
dimensions of poverty. But the pace of reduction has been slow, and in some countries
extremely slow. The South Asians have been described as the income-poorest, one of the
most illiterate, the most malnourished, the least gender sensitive, rendering the region
with highest human poverty of the world.1
1 The concept of "human poverty" relates to "human development" much the
same way income-poverty relates to economic growth and, as such, captures
deprivations in all key dimensions of human development. The idea is elaborated
in the background paper prepared by Sudhir Anand and Amartya Sen for the 1997
UNDP Human Development Report. It has been defined, In the broad terms, as the
"denial of opportunities and choices most basic to human development--to lead a
long, healthy and creative life and to enjoy a decent standard of living,
freedom, dignity, self-esteem and the respect of others".
1
The centrality of human poverty reduction in South Asia as a major contributing factor
to economic growth, income poverty reduction, and the general level of human
development, is widely recognized.23Recent advances in theoretical and empirical literature
on economic development indicate that regions and nations with lower initial human
poverty are likely Io have higher and sustainable economic growth, faster income poverty
reduction and much higher levels of general human development. This is clearly borne out
by the developmental experience of South Asia over the last four decades and, indeed,
constitutes the most important policy message emerging from the review attempted in this
paper.
Why the progress on human poverty reduction was extremely slow in South Asia? This is
the question that looms large in the backdrop of the successes of the East and South East
Asian countries. The present paper attempts to address this question by assembling
supportive evidence on the countries of the region.3
The paper is motivated by the general approach of looking for lessons for South Asia from
within and from the diversity of its own experiences. The findings supplement what can
be learned from international comparisons of successes and failures in economic
development and poverty reduction.
2 The centrality of this factor has been well recognized in recent
intellectual traditions. It has been forcefully put forward in the human
development literature, as in the case of successive Human Development Reports
of UNDP. It has also been instrumental in the emergence of "new" growth-economics
where "human capital" with implications for technological progress and positive
externalities work as the driving force behind economic growth. The recent
argument put forward in the World Development Report 1999 regarding increasing
knowledge-gaps between and within countries as a factor of persistent divergence
is derivative of the human capital-centric growth discourse. However, the
distinction between "human development" and "human capital" needs to be kept in
view as well. The concept of human development has a deeper, intrinsic value as
an end (goal) of development. It is an objective that is to be valued for its own
sake. But, something that is intrinsically important can also have the added
advantage of being instrumentally conducive to achieving more conventional goals
of economic success, without compromising its intrinsic value. Thus, human
development can and does contribute to economic growth, to income-poverty
reduction and to other usual measures of economic performance, but its value does
not lie only in these instrumental contributions. A human development based
criterion of judging economic success would, in turn, require these instrumental
contributions to economic performance to actually trannlate Into still higher and
sustained levels of human development in a virtuous circle. In contrast, the
notion of human capital is very much focused on the economic contributions of
expansions of "human resources" as if people were just the means of production
and not its ultimate end. As Amartya Sen (1998) pointed out that "the bettering
of human life does not have to be justified by showing that a person with a
better life is also a better producer" (p. 6). It is, of course, fair to
acknowledge that new theories of economic growth putting emphasis on investing
in peoples as a faster way of expediting economic progress and climbing out of
income poverty are a big leap forward over the standard growth theories.
3 Data used in this paper are taken from Sen and Rahman (1998),
Development Report, and 1999/00 World Development Report.
1997 Human
2
Mere recognition of the centrality of the factor of human poverty reduction is not enough.
One needs to identify the links that render some policies and processes conducive to faster
human poverty reduction. A review of diverse South Asian experience identifies four broad
links. These pertain to pro-poor growth policies leading to income-poverty reduction,
policies for reducing income (asset) inequality, broad-based and effective access to basic
public provisionings, and gender empowerment. Each is reviewed in turn.
II. Slow Progress in Income-Poverty as Barrier to Faster Reduction in HumanPoverty
One of the key factors inhibiting the faster rate of human development has been the very
slow progress in income-poverty. The rate of national income poverty reduction, as
measured by the proportion of households below poverty line, has been minimal—less than
1 percentage point per year in all the countries of South Asia under review over the last
two decades. Progress in human poverty would have been at a much higher rate had there
been commensurate progress in income poverty, since a reduction in the latter creates
private purchasing power, leading to further (private) investment in human capital and
hence greater improvements in human poverty. The importance of this channel becomes
even more transparent in the South Asian contexts with weak state capacities and
endemic misgovernance over public goods access. Even for contexts where such capacities
are pre-existent, the need for demand-driven mechanism (voices) "from below" is seen as
a critical factor for effective functioning of the state. Such "voices from below" are, of
course, a direct function of the level of empowerment in a society. But, they are also
indirectly influenced by income-poverty reduction. In the South Asian context the incomepoorest are also the most hard-hit category when it comes to accessing quality public
sendees.1*45In short, policies that reduce income-poverty also help faster human poverty
reduction via allowing the poor to meet the costs of publicly and privately provided services
as well as through expressing greater voices influencing the access to, and quality of,
public social services.
The very slow pace of income-poverty reduction is partly due to the fact that South Asian
economies did not grow fast enough over the last two decades, or for that matter, during
the entire period since the early sixties. The overall record in terms of per capita GDP
growth has been modest judged by the standards of East and South East Asian
economies. Between 1960 and 1997, per capita GDP trend growth rate in Sri Lanka was
2.84 per cent per annum, followed by India (2.13 per cent), Bangladesh (0.96 per cent),
and Nepal (0.92 per cent). This may be contrasted to the matched figures of 6.43 per cent
in South Korea, followed by 6.29 per cent in Singapore, 6.06 per cent in China, 5.01 per
cent in Thailand, 4.55 per cent in Indonesia, and 4.10 per cent in Malaysia recorded
during the same period.5 Even in contexts where one could observe relatively high GDP
1 Significant quality differentials exist in the access to basic social
services such as between the poor and the rich districts (and households). For
some evidence on India's basic education carried out by the PROBE team, see De
et al (1999).
5 The estimates are based on data provided in World Development Indicators.
3
growth rate in the sixties quite at par with the historically observed rates for the highperforming Asian economies (HPAE), there has been a striking slow down in the recent
decades, especially since the early eighties. Thus, in Pakistan which had the most
impressive growth record in South Asia, the rate of growth in per cnpiln GDP declined
from the high point ol 3.-18 per cent in 1960-73 to the low-point of 2.47 per cent in the
1983-97 period.6
The relatively slow rate of economic growth is attributable to two principal factors found
particularly compelling in the South Asian context. First, growth potentials were
undermined--at various degrees in all the countries of South Asia--by the persistence of
inward-looking import-substitution oriented (ISO) development strategies in the entire
period from the fifties through the eighties. This has eventually resulted in relatively high
and rising incremental capital-output ratios and consequent slow down of growth for a
given level of savings rate.7 Adoption of such a strategy was influenced by the doctrines
of economic nationalism and the attendant ideas relating to infant-industry protection.
Stark contrast to these is provided by the booming international trading environment
during 1950-72 and inability of the countries of the region to exploit the powerful
instrumental role of international trade in stepping up domestic rate of economic growth.
Continued reliance on the ISO strategy even in the face of the changed circumstances of
seventies (following the oil-shocks) and eighties (following the debt crisis) could only
magnify adverse long-term growth implications of such a strategy. Two such implications
may be highlighted here.
First, lack of openness (in general) and export-pessimism (in particular), that accompanied
such inward-orientated strategy, also meant that the rate of technological progress has
been slower in the South Asian economies compared to the East and South East Asia
throughout this period, further undermining the potentials of long-term economic
6 The per capita GDP growth rate in Pakistan during 1973-83 was lower than the
sixties but still impressive at 3.28 per cent. Pakistan could sustain high-growth
in the seventies despite having large fiscal deficits because the real interest
rates on external debt were substantially negative during that period so debt-toGDP ratios continued to decline till 1981. But the trend has been sharply
reversed since then as the real interest rates turned positive in the eighties,
with external debt rising from a low of around 37 per cent of GDP in 1981 to over
53 per cent in 1991. Pakistan quickly entered into a debt crisis which had
adverse implications for growth and income poverty reduction during the nineties
(see, Ahmed 1994) .
7 The policy package associated with the import - substitution-oriented strategy
had certain and, by now, well-known features. The package includes measures such
as keeping the exchange rate overvalued (in the then prevailing system of fixed
exchange rates), the imposition of various quantitative controls on foreign
exchange and imports, and the graded tariffs (highest on consumer goods, lower
on intermediates and the lowest on capital goods) to contain the excess demand
for foreign exchange resulting from overvalued currency. It discriminated against
exports and resulted in perpetual balance-of-payments deficits which, in turn,
led to further tightening of import controls in an unending cycle. It has
discriminated against agriculture, which was the major source of primary exports.
4
growth.8 Second, and perhaps more importantly, the policy-induced distortions created
initiallj' by the need for adopting inward-looking strategy aggravated, rather than reduced,
the pre-existing dualisms between the traditional and modem segments in the output and
factor markets (specially, in labor and capital markets). This has further eroded the basis
for broad-based, shared, economic growth with potentials for faster income-poverty
reduction.9 Note that these distortions are rather difficult to overcome even as the
governments of South Asia attempt to carry out outward-oriented policy reforms because
the distortions have by now taken deeper institutional roots, persisting as negative
institutional structures and superstructures vested with strong political economy interests
(North 1990; 1994). This is evidenced from the experience of the eighties and the nineties
which saw successive moves towards policy reforms in all the South Asian economies to
bring more openness, transparency and accountability to the system with emphasis on
market regulators and private sector. The progress on these fronts was remarkably slow
and the anti-poverty effects of these reforms, as measured by the corresponding poverty
ratios, were clearlj’ modest. This is largely because the institutions created by the past
strategy of inward-orientation continue to remain as a drag on growth, giving rise to newer
forms of distributional conflicts and breeding instabilities in the reform process itself.
While the product-market distortions emerging from restrictive trade and exchange rate
policies under centrally initiated and public sector-oriented industrialization was a major
causal factor behind the slow pace of economic growth in South Asia vis-a-vis the HPAEs,
the situation was aggravated further by the relative--and conspicuous— absence of the
second, no less important, factor, namely, broad-based human development. The latter
is epitomized by the fact that only less than 50 per cent of the South Asian population
could get access to basic literacy even 50 years after the end of the colonial rule. The
poverty-impact of economic growth was severely undercut by the very low level of public
investments in human development in all the South Asian societies except Sri Lanka and
8 The cost of neglecting the importance of greater integration with the world
market (in general) and trade (in particular) as one of the factors of economic
and social progress in South Asia has been considerable. As Amartya Sen (1998)
has noted in the Indian context, "the scope of and rewards from greater
integration with the world market have been and are large, and India too can reap
much more fully the benefits of economies of scale and efficient division of
labor that many other countries have already successfully used. While greater
reliance on trade is sometimes seen as something that compromises a country's
economic independence, that view is hard to sustain. Given the diversity of
trading partners and the interest of the different partners to have access to the
large economic market in India, the fear that India would be an economic prisoner
in the international world of open exchange is quite unfounded. This does not
deny the importance of getting the terms and conditions right, including having
fair regulations from GATT
(or its successor)
and other international
institutions. But in general there is little reason for fearfully abstaining from
the benefits offered by the greater use of the facilities of international trade
and exchange" (p.9).
9 There is a fairly large body of literature on "dualism" in the context of
developing countries. On the nature and consequences of "dualism" in the backdrop
of inward-looking development strategy, see Myint (1971; 1985).
5
Maldives. 10 On one hand, this was a consequence of poor economic growth, as the
governments in slow-growing economies have limited resources at their disposal to finance
human development. But, this may provide only a part of the explanation, valid mostly for
periods when a particular government was under severe fiscal constraints. But, South
Asian governments never allocated the right amount of resources to the eradication of
human poverty that it deserved even when they embarked on large-scale public
investment programs. Thus, even when the economies in the region were growing at
considerable pace, fiscal commitments to the removal of illiteracy, to the eradication of
preventable diseases, and to the elimination of the very high level of malnutrition among
women and children were minimal, to say the least. The case of Pakistan illustrates the
point. While it was evidently the fastest growing economy in South Asia, its performance
on account of a number of human development indicators lagged behind its neighbors
with relatively low level of per capita GDP. For instance, Pakistan had the highest infant
mortality rate in 1996 (101 against 74 in India, 77 in Bangladesh, and 79 in Nepal). It also
had the region's second lowest literacy rate (after Nepal). 11
Serious disparity in the level of human poverty exists among the Indian states. Some of
the states such as Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh have been
persistently poor performer in respect of basic education and health. These states have
the highest illiteracy rates, highest' mortality rates, and highest prevalence of child
malnutrition. 12In all these respects, these states paint a worse scenario than the average
South Asian picture. 13
10 This is equally true for Myanmar (Burma) which was once considered part of the
South Asia. In both the contexts a favorable confluence of a variety of
institutional factors--including the strong egalitarian and populist traditions
of Buddhism--led to, typically, historically higher initial levels of basic
literacy compared to the other countries of South Asia. It is often maintained
that Buddhist countries have typically had much higher levels of basic literacy
than societies dominated by Hinduism or Islam. This, however, should not be seen
as an "essentialist" explanation leading to some historical inevitability in the
predictable direction, as there is considerable variation in the sociology and
institution of the same religious tradition across the countries. For instance,
in 1995, adult literacy rate among women was 93 per cent in Maldives, which is
highest among South Asia. In this respect, it tops the list among all member
countries of the Islamic Conference, much ahead of HPAEs such as Malaysia and
Indonesia. In short, the case of Maldives provides yet another example of how the
influence of "traditions" can be overcome through pro-active public policy and
social action.
11 Indeed, Pakistan has made very slow progress in gross primary enrollment. In
India and Sri Lanka the rates now exceed 100% and Bangladesh's rate is coming
close. Pakistan has also shown some improvement, but is still only at 67%.
12 The illiteracy rate in these states was 56-62% as against the all-India
average of 48% in 1991. The mortality rate, as captured by "probability of dying
before 40", was in the range between 20-26% compared with the Indian average of
18% in 1989-93. Similarly, the proportion of underweight was 58-63% vs. 54% for
all-India in 1992-93. The prevalence of malnutrition among under-five children
is somewhat lower in Rajasthan, being assessed at 42%. The Indian-state level
data are taken from Prabhu (1998).
13
The above-mentioned four states together with Andhra Pradesh are often aptly
6
There is no adequate explanation for the stunning lack of commensurate public action in
the area of human development in South Asin. In India, for which the relevant data are
available, the contrast between the goveinment'n attention to higher education and neglect
of primary education had been intolerably large already in the sixties. That gap has, if
anything, grown rather than shrunk over the subsequent period. Indeed, judged in 'real'
terms, the percentage expansion of the number of teachers has actually fallen steadily
from the fifties, to the sixties, to the seventies, and through the eighties, from 5.6 per cent
per year during 1950-60 to 1.6 per cent during 1985-90 (Dreze and Sen 1995). The root
cause for low investment in elementary education is possibly located in the "deep-seated
class biases" that shaped distorted educational priorities. 14
The above should not create the impression that it is the relative slowness of South Asian
economies vis-a-vis the HPAEs only matters for still slower pace of progress in income
poverty. What is at stake is not just the issue of average growth rate, though that was
surely an important aspect in the whole development narrative. Given the nature of the
growth process, as summarily discussed above, it is hardly surprising that the outcome
was quite modest not only in terms of growth rate, but also in respect of possible growth
impact on the poor. Distributionally, whatever growth that has taken place in South Asia,
it did not favor the poor as much as one would have expected given the politics of "garibi
hatao", and in some countries and periods, it was clearly anti-poor. Thus, both the issues
of accelerating per capita GDP growth rate, on one hand, and the participatory nature of
the growth process, on the other, need to be given due weights so that the pace of
subsequent economic growth can be raised further for faster income-poverty reduction.
As a result of policy-distortions associated with the ISO strategy and as a consequence of
low public investments in human development, the poor in South Asia had very limited
summed up as BIMARU (literally, the "sick") states of India because of their
relatively poor performance--in overall judgment--1n areas of health, nutrition,
and education indicators.
14 We owe this sociological explanation to Amartya Sen who pointed out in the
1970 Lal Bahadur Shastri Memorial Lecture entitled "The Crisis in Indian
Education" that the above-mentioned "inequalities in education are, in fact, a
reflection of inequalities of economic and social powers of different groups in
India". His later commentaries on the issue is worth quoting in full given the
contemporary relevance: "The educational inequalities both reflect and help to
sustain social disparities, and for a real break, much more determined political
action would be needed than has been provided so far by those in office, or by
parties that have led the opposition. The traditionally elitist tendencies of the
ruling cultural and religious traditions in India may have added to the political
problem here" (Sen 1998, p.14). The persistence of endemic illiteracy and
educational backwardness in South Asia had many side effects affecting other
dimensions of human poverty reduction. For instance, it had a direct role in the
relative deprivation of women, sustaining high mortality levels and fertility
rates. It contributed to "low voices" and poor quality of democracy. These are
over and above the point that the lack of elementary education also makes the
realization of broader growth objectives (including integration with the world
market) extremely difficult.
7
participation in the economic growth process outside agriculture and informal sectors
where the return to labor was typically low. Poverty reduction thus became dependent on
the growth potentials of these sectors which, by the very nature of policy biases discussed
earlier, were placed in a much more disadvantageous position vis-a-vis the modern sector
under a dualist economic setting. Because of such discriminations, there has been very
limited productivity improvements in these sectors, undermining their long-term growth
potentials. However, the experience of South Asia also shows that whenever these sectors
had the chance to perform well, the pace of income poverty reduction was faster. The
spells with fastest poverty reduction rates were also the periods when the agricultural
growth rates were high, as observed in case of all three countries--Bangladesh, Pakistan
and India--during the period between mid-seventies and mid-eighties. 15 Note that
agriculture was discriminated under the inward-looking development strategy pursued in
the past, though the extent of discrimination varied according to the degree of inward
orientation, the latter being highest in India, followed by its neighbors. In case of Nepal the
very slow overall reduction of poverty is mainly attributable to the poor performance of the
agricultural sector. Of particular disturbing feature is the slow-down of agricultural growth
since the late eighties in almost all the countries of South Asia.
Even this slow progress in income-poverty at the average national level masks significant
regional and social differentiation. Although the inter-temporal comparisons are not
always available, the cross-sectional variations in the poverty rates are large across social
and regional characteristics. There are clear biases in poverty and social exclusion that
favor majoritarian formations, as evidenced in the disparities between high-caste and lowcaste (as in India and Nepal), between majority and minority groups classified according
to ethnicity and religion (cutting across nearly all the countries of the region), and between
advanced and backward areas. Social differentiation often reinforces and ossifies regional
differentiation, and vice versa. This indicates the persistent negative influence of broader
political and cultural factors that favour particular region, community, ethnicity, caste and
religious groups. Without removal of (or, at the least, counteracting) these barriers, the
participation of socially disadvantaged groups in the growth process would remain
circumscribed and the faster progress in income-poverty at the national level would
remain a daunting task.
Faster reduction of income-poverty is closely connected with the issue of fostering pro-poor
(equitable) economic growth. If growth is accompanied by rising income inequality,
opportunities are missed for poverty reduction.
15 This implies that the "green revolution" eventually turned out to be pro-poor
even on distributional terms, despite some initial disadvantage of the small
farmers, which was gradually overcome as the process of diffusion of new
technology in agriculture became operative over a larger area and variety. It is
altogether a different story that a considerable part of the potentially
irrigable land is still without such facility while the yield on the new variety
remains much lower than the comparable international examples. There are also
growing challenges on grounds of environmental sustainability. Without having
adequate funding for research encouraging diversified agriculture and deep
cutting institutional reforms in the entire loop connecting agricultural research
and extension, on one hand, and suitable land-tenurial and local government
reforms, on the other, such pitfalls in the further modernization of agriculture
would continue to persist.
8
HI. Rising Inequality as Barrier to Faster Reduction in Human-Poverty
Many of the South Asian economies have entered into relatively high levels of income
inequality' at relatively low levels of income judged by the East and South Asian standard.
Managing inequality has thus emerged as a separate area of policy concern along side the
compulsion for reducing income-poverty. This has been a rather new trend in the nineties.
Inequality appears to be rising in all countries of South Asia except Sri Lanka for which
income data are available. 16 This has been happening even in countries where it had long
remained relatively unchanged, leading many people to dismiss it as a peripheral concern.
In Bangladesh between the early eighties and early nineties the Gini index for measuring
relative inequality was 0.24 to 0.26, based on consumption data, and 0.35 to 0.36, based
on income data. Recently released data for 1995/96, however, indicate a sharp rise--to
0.29 based on consumption, or 0.39 based on income. The increase has been even greater
in urban areas: based on consumption it rose from around 0.32 in the 1980s to 0.37 in
16 Income data are not available for India to carry out inter-temporal
comparison, which appears to be the most important knowledge-gap when it comes
to monitoring welfare in the Indian context. In Sri Lanka most of the
improvements in distribution of income (consumption) took place during the later
half of the eighties. The Gini index for relative inequality in Sri Lanka was
0.34 in 1985/86 compared with 0.32 in 1990/91, based on consumption data. The
corresponding figures based on income data were 0.49 and 0.44, respectively. Data
for the recent period show marginal improvement: from 0.32 in 1990/91 to 0.321
in 1995/96, as per consumption data, and from 0.44 to 0.429, according to income
data .
9
1995/96, and based on income the rise was from 0.37 to 0.44.17 There have been similar
rises in both rural and urban inequality in Pakistan and Nepal.
17 Income-based Gini estimates for Bangladesh, as mentioned above, are carried
out by the Bangladesh Bureau of Statistics (BBS). The definition of "current
income" adopted by BBS includes capital receipts such as revenue from sale of
assets; withdrawal from working capital, saving deposits and provident funds;
repayment of loans made to others in the past, and borrowing. These clearly do
not belong to income according to any acceptable definition. A revised estimate
of Gini index excluding these items yield a considerably lower level of
inequality: 0.310 as per the revised estimate vis-a-vis 0.384 as per BBS for
1995/96 (Khan and Sen 1999) . However, the underlying trend of sharply rising
inequality still comes through the data. The Bangladesh example is also
instructive from the point of view generating estimates based on uniform
definition for assessing comparative level of and monitoring change in income
inequality in South Asia.
10
Growing income (asset) inequality has a dampening effect on the subsequent economic
growth as well, though much more research is needed in this area in South Asia. The
impact of inequality works through several channels. Increasing inequality may be
accompanied by higher political instability, and hence disrupting the growth process. This
is the standard political economy argument associated with higher inequality. 18 The other
influential argument is also linked with political economy, but this time the effect is
operating through the fiscal channel. The higher the inequality, the greater (especially in
democracies) the compulsion for making redistributive transfers. As these resources are
likely to be diverted for supporting consumption, it may reduce the aggregate public
investment rate, thereby leading to slower growth. If the resources thus diverted through
the public channel contribute to increasing public debt, then the resulting process may
even have some "crowding out" effects, depressing the level of private investment. 19
Higher inequality in asset distribution also limits the poor's capacity for borrowing against
collaterals and hence puts constraints on financing education as a way of climbing out of
poverty. Even if the borrowing without collateral takes place, it is likely to be cheaper to
acquire education out of one's own (or one's parents') savings instead of by borrowing from
the capital market. One of the implications of this line of reasoning is that more equitable
distribution of physical assets will help the process of accumulation of "human capital"
and hence, long-term economic growth. All these arguments are in operation in South Asia
in varying degree.
In short, high income inequality dampens the pace of human poverty reduction in two
major ways: first, indirectly, through lowering the pace of income-poverty reduction by
negatively impacting on growth; and second, directly, via limiting poor's own capacity to
invest in human development in the backdrop a credit market that tends to exclude the
assetless poor. High income-poverty causes low investment in mother and child health
and nutrition, having adverse implications for the future schooling performance and
productivity. Low household income also leads to high dropout and greater incidence of
child labor. Policies that promote pro-poor equitable growth policies thus need to be
pursued in order to break the links that bind high inequality, low-income growth, and slow
income poverty reduction in a vicious circle.
18 There is a growing body of literature on how inequality can affect subsequent
economic growth and poverty reduction. See, Perotti (1992), Galor and Zeira
(1993), Banerjee and Newman (1993), Persson and Tabellini (1994), Birdsall and
Sabot (1994), Alesina and Rodrik (1994), Ravallion and Chen (1997).
19 Another fiscal version of this argument --proposed by Alesina and Rodrik
(1994)--st 1pulates that the compulsion for making redistributive transfers leads
to the imposition of higher distortionary taxes on the private investors, which,
in turn, reduces private investment and hence, overall economic growth. In the
South Asian context, however, the problem always has been one of inability to tax
the rich in the first place rather than the distortions that such tax system
entails. The share of direct taxes (income and corporate tax, wealth tax) in
total tax revenue is typically very low in South Asia, being restricted to the
order of 20%. The matched figure has changed very little over the last two
decades. Thus, in Pakistan, the share of direct taxes in total tax revenue has
actually registered minor decline from 17 to 14 per cent over the period between
1976 and 1986 (Ahmad and Stern 1991).
11
IV. Limited Access to Basic Public Goods as Barrier to Faster Reduction in HumanPoverty
With slow income growth, potentials for generating public revenue decline, thereby leading
to the underprovisioning of public goods—a factor of paramount importance in human
poverty reduction.
Basic public goods such as education, health, water, sanitation road, electricity, disaster
management, and decent environment strongly influence human poverty reduction. The
effect percolates through three main channels. First, it indirectly influences the pace of
reduction of income-poverty by providing the poor non-market access to basic social
services as well as by linking them with the upstream markets. Second, some of the basic
public goods such as health and disaster management can prevent consumption shocks
and/or help the coping capability of the income-poor. Mechanism for preventing income
erosion via effective public provisioning is an important policy arena in its own right. But,
the added benefit is that it also helps the human poverty reduction process since the
consumption shocks have adverse implications for the nutritional status of the children
as well as women, apart from the generally downward pressures in poverty associated with
them. Third, it has a direct importance of its own, having bearing on the capability of the
income-poor. The current state in South Asia in this respect leaves much to be desired
despite some progress over time.
Public spending on education as proportion of GNP has increased in all the South Asian
countries during 1980-96 for which data are available for international comparisons. .India
and Sri Lanka top the list in 1996 by allocating 3.4 per cent of its national income to
public education, closely followed by Pakistan (3%), Bangladesh (2.9%) and Nepal (2.8%).
Bangladesh's pace of progress was fastest during this period, as it could double the
matched allocations from 1.5 to 3 per cent, thereby closing the gap with its neighbors. In
contrast, there has been a very slow rise in public allocations for education in India (from
3 to 3.4 per cent) as well as Sri Lanka (from 2.7 to 3.4 per cent). Both Pakistan and Nepal
experienced moderate increase.
The average figure for South Asia has increased from 2 per cent in 1980 to 3 per cent in
1996. This is lower than the 1996 average reported for the low-income countries (3.9 per
cent) and much lower than the average for the middle-income (5.1 per cent). This shows
that education is still not getting the attention it deserves in South Asia where the
currently attained level of average affluence leaves considerable scope for increasing public
allocations for tire sector. There is also much room for improvement in allocating resources
among the various sub-sectors, which needs to be attuned to the critical need of universal
coverage of quality primary education. The comparative fiscal data for different levels of
public education—the more relevant indicator for international comparison—is, however,
currently not available.20
20 But, as discussed earlier, the progress in primary enrollment (which is mostly
driven by public expenditures) has been fairly uneven across the countries of the
region, which may imply different allocation biases within public education. This
aspect needs to be documented further.
12
A more disturbing picture emerges when one considers the international data on public
spending on health, expressed as share of GNP, though here the lack of information is
even more acute.21 Notwithstanding the gaps in data, two aspects are still noteworthy.
Firstly, the insufficiency of public allocations for health in South Asia is particularly
revealing in comparative perspective. Thus, public spending on health as proportion of
GNP shows a secular increase, from just 1 per cent in low-income countries to 2.4 per cent
in middle-income countries, rising to as high as 6 per cent for high-income countries. The
corresponding figure for South Asia is only 0.8 per cent.
Secondly, considerable difference exists within the region. The highest allocation for public
health was in Sri Lanka during the nineties (1.4 per cent), followed by Bangladesh and
Nepal (1.2 per cent each), with Pakistan and India at the bottom of the table (0.8 and 0.7
per cent, respectively). Public allocations for health must be increased to at least 2-2.5 per
cent in order to make any significant health-impact out of economic growth in South Asia.
Of course, mere increase in allocations will not necessarily lead to improvements in health
care access and health status of the poor. The same applies to public education as well.
For that one needs to improve upon the governance dimensions pertaining to public health
and education. But, it is equally clear that policies for good governance in administering
allocations for education and health have to weigh the current allocation priorities.
Countries of South Asia need more doctors, nurses, primary health clinics, teachers,
schools to better service the needs of the growing population, which also mean more
allocations these sectors. The latter will also help to improve the quality of services. For
instance, the student-teacher ratio has increased considerably in Bangladesh and
Pakistan--the two countries for which inter-temporal data are available.22To counteract
these tendencies requires more teachers, classrooms, and schools. There are also
problems of intra-sectoral imbalances and policy distortions. In Bangladesh, for instance,
there is an urgent need to increase the number of trained nurses, as it is the only country
in South Asia where tire number of doctors exceed the number of trained nurses by a large
margin. Distorted priorities of this kind need to be removed, and social sector allocations
must truly reflect the needs and choices of the people of South Asia.
In practice, "voices of the people" remained rather weak in influencing the priorities of
public allocations for social sectors such as education, health and nutrition. On the
contrary, often the pattern of social allocations has even exacerbated the pre-existing
inequality in the system. Income inequality is only one face of the various inequities that
exist in South Asian societies. The region is characterized by a very high degree of
21 Both education and health data refer to the World Development Report 1999/2000
published by the World Bank and Human Development Report 1999 prepared by the
UNDP. Public health data are insufficient on two counts. First, there is no
reliable estimates regarding the directionality of the change in the indicator:
we have only the average allocation ratio for the 1990-97 period. Second, as in
the case of public education, allocations among various sub-sectors of public
health are missing, which is a crucial gap in our knowledge.
22 In Bangladesh, the student-teacher ratio has increased from 50 in 1981/82 to
66 in 1995/96. The matched figure in Pakistan has risen from 38 to 46 during
1984-96.
13
inequality in the access to basic public goods. This is seen in the sharp and widening
contrasts between agriculturally backward and advanced regions, high and low castes,
majorities and minorities, rural and urban areas, in general between income-poor and
non-poor. across cultures and nations. Thus, average pictures of progress in human
development indicators conceal significant variation along the above lines of social, racial
and regional divide.
Even in contexts where allocations for such provisionings increased as an overall
budgetary ratio, the outcome was no better, because of leakage and deteriorating service
quality. The effective functioning of the publicly provided basic social services represents
one of the most important barriers to human-poverty reduction in South Asia. Such a
functioning pre-requires a system of good governance through decentralisation and
regulatory frameworks, on one side, and an equally effective pressure mechanism of
people's organisations, citizens and consumers from below. There are a number of best
practice examples in South Asia in this regard, but they seem to have by-passed the
attention of the planners and the policymakers of the region at large. Learning from one's
own civilisational past and from the experience of the South Asian neighbours has been
a rarity in the post-colonial "national" quests for poverty eradication.
There are some innovative programs and policies initiated in South Asia which are not
only relevant from the view-point of attaining "good governance", but also from their
proven success in terms of imparting "greater voices" to the poor people. There are some
larger-scalc, "macro", success stories involving the entire territory of a state, though,
admittedly, they were few in numbers. The success of elementary education and health
in Kerala is much discussed, but still an instructive case in point. Of course, Kerala has
had a rather special history of social initiatives. But, as Amartya Sen pointed out, "a
region need not be imprisoned in the fixity of its history, and much depends on what is
done here and now" (Sen 1998, p. 17). 23 Kerala's success points to the importance of
political leadership and initiative and of popular involvement. But, there are other kinds
of "micro" success stories, ranging from BRAC's non-formal primary education in
Bangladesh, social mobilization program pioneered by the AKRSP in Pakistan and now
being implemented in all the countries of South Asia, to give some recent examples. 24
V. Women Disempowerment as Barrier to Faster Reduction in Human-Poverty
23 This is clearly seen from the account of how the historical heterogeneity
within Kerala was overcome through determined public action. When the state of
Kerala was created in Independent India, it was made up, on linguistic grounds,
of the erstwhile native states of Travancore and Cochin, and the region of
Malabar from the old province of Madras in British India. The Malabar region was
very much behind Travancore and Cochin in social development (including literacy,
life expectancy, and mortality rates) . The initiatives taken by the successive
state governments of Kerala (which included regimes led by the Communist Party
as well as by the Congress) succeeded in transforming Malabar. By the eighties,
Malabar had so much "caught up" with the rest of Kerala that one could hardly see
any inter-regional difference.
24 Compared with education, micro successes in primary health and nutritional
care targeted to the poor communities were much less, and, as such, stand out
as the key institutional challenge facing social development in South Asia.
14
Over the past two decades, women's status and opportunities have improved in South
Asia. The improvement has been brought about by increased job opportunities,
demographic change, better education, and better household technologies. These forces
have partly liberalized women from childbearing, have enhanced their relative productivity
outside the home, and have increased their voice in household spending decisions.
Nonetheless. South Asian women face enormous challenges. The role of women in
development varies considerably across the region.
The relative neglect of female agency in the process of development has been one of the
most persistent cause of slow per capita GDP growth as well as sluggish rate of human
poverty reduction in South Asia, especially when one compares with the experience of East
and South-East Asia. This has effects at several levels. Recent theoretical and empirical
works suggest that societies with higher "women empowerment" have been most
successful in reducing population growth, infant and child mortality, and achieving better
nutritional status of children and their performance at schools, with implications for
productivity of the nation. This has been vindicated by the South Asian experience.
Available macro and micro-level evidence provides ample statistical basis to support this.
Let us consider first the links between women empowerment and fertility rate, having
bearing on population growth and, through the latter, on growth in per capita income.25
Thus, a study by Murthi et al (1995) considered a range of factors for explaining observed
variation in fertility rate across the Indian districts.26 The list included factors such as the
incidence of income-poverty, male literacy, female literacy, female work force participation,
extent of urbanization, access to medical facilities, share of socially disadvantaged groups
such as scheduled tribe and scheduled castes in the population, and specificity of
geographical locations. It turned out that, among all the usual candidates for causal
analysis, the only ones that have a statistically significant effect in reducing fertility rate
are those related to higher women empowerment, i.e., higher female literacy and greater
female work force participation. 27 The independent impact of women empowerment was
25 The endogeneity of population growth is well-recognized in new growth theory.
Among various factors that can influence decisions to reduce fertility, women's
agency appears to be one of the most important causal links. For further details,
see Galor and Weil (1996), Schultz (1985).
26 The study is based on 1981 census data and relates to a sample of 296
districts located in 14 of India's 15 most populated states. These 14 states
contained 326 districts in 1981 and accounted for 94 per cent of the total
population of India. The missing state is Assam where the 1981 census was not
conducted.
27 Two issues stand out as potentially important routes for further research.
First, there is scope for probing further into the issue of "women empowerment"
as the conventional variables ouch an literacy and labor force participation may
not adequately capture the level and/or quality of empowerment. Second, the
analysis pirnenlrd In Muithl el nl (199'1) a I no suggest.od that feil'lllty I ti
significantly lowei In the noullirill and wentein legions of India and In dint rials
with a high proportion of scheduled tribes. The latter finding is sociologically
curious and warrants further scrutiny.
15
also crucially important (along side the economic factors such as income-poverty, access
to medical services, and urbanization) in explaining cross-district differentials in other
aspects relating to human poverty such as under-five child mortality and female
disadvantage in child survival.
The links between women empowerment and fertility also explain why some of the richest
Indian states such as Punjab and Haryana have higher fertility rates compared to those
in the South, which have lower incomes per capita but higher female literacy rates and
female job opportunities. The argument is equally valid in case of cross-country
comparisons within South Asia as well. Thus, Pakistan has about twice the level of per
capita income than in Bangladesh, but it also has nearly twice as high fertility rate.28 The
resultant divergence in fertility rate between the two countries has become particularly
pronounced in the nineties with comparatively rapid progress in female literacy, female
labor force participation, and contraceptive prevalence rate among currently married
women in Bangladesh.29
28 According to the 1997 Human Development Report, GNP per capita in 1994 in
Pakistan and Bangladesh was 220 and 430 US$, respectively. The fertility rate in
these countries was 5.5 and 2.9 in 1994, according to the same report. As per the
1996/97 Demographic and Health Survey, however, the fertility rate in Bangladesh
is 3.3.
29 Admittedly, more works--including construction of reliable time series on
basic indicators such as labor force participation, enrollment and mortality
rates--need to be carried out to capture the comparative social progress in South
Asia. Nevertheless, fairly striking cross■country contrasts in some of the key
social indicators emerge from the available data. For instance, the adult (15+)
female literacy rate in Pakistan was assessed at 27% in 1996/97, which may be
compared with 38.4% recorded for Bangladesh in 1996. In general, one could see
comparatively faster spread of primary education among girls in Bangladesh during
the nineties. As a result, the gross enrollment rate at primary level for girls
in Bangladesh was over 80% compared with 50% observed in Pakistan in 1993. The
faster pace of progress in enrollment in Bangladesh is also vindicated by the 62village panel survey carried out by BIDS in 1989/90 and 1994, showing a rapid
increase in net female enrollment at primary level in rural areas--from 52 to 70
per cent. Similarly, the female (10+) labor force participation rate was found
considerably higher in Bangladesh vis-a-vis Pakistan (18.1% in 1995/96 compared
with 7.6% in 1994/95). Note that in line with the results relating to female
literacy and work force participation ratio, the contraceptive prevalence rate
among currently married women has been predictably higher in Bangladesh than in
Pakistan (46% compared with 22% in 1996/97). The relatively high contraceptive
prevalence rate in Bangladesh was caused by several .factors. It may be seen as
a consequence of falling demand for children as the opportunity cost of children
went up in response to economic and social changes. It is also a result of a
well-designed public policy, signaling the advent of a "new social norm" in which
lower desired fertility was actually viewed socially as a "good thing". The
signaling function of the population control program was seen to be a more
important factor in the success story than the usual function of wider and easy
access. The rapid fall in the fertility rate in Bangladesh has drawn considerable
attention in the recent years (see, for instance, Phillips et al 1988, ADB 1997,
Adnan 1998, Ray 1999, Mahmud 1999) .
16
Another way of capturing the role of "women's agency" in fostering rapid reduction in
human poverty is to consider the links that exist between maternal malnutrition and
health care, on one hand, and the nutritional status of children and their subsequent
academic performance at schools, on the other. Such links have strong implications for
human capital formation, productivity, and future economic growth of the nations.
The state of maternal malnutrition and health care is extremely poor in South Asia.
Maternal mortality rate estimated for this region is higher than the matched average for
the developing countries. Considerable variation exists within the region itself, with Sri
Lanka having the lowest maternal mortality rate (240 per 100,000 live births) compared
with 539 for Nepal, 440 for Bangladesh, 437 for India, and 340 for Pakistan.30The higher
the level of maternal malnutrition the greater is the likely incidence of "low birth-weight"
infants.31 The latter ranges from the high point of 50% in Bangladesh to 33% in India,
25% in Sri Lanka and Pakistan. Higher incidence of low birth-weight infants also explains
the relatively high prevalence of malnutrition among under-five children in India and
Bangladesh. Thus, the share of underweight among children under 5 years varies from
37% in Sri Lanka (1993) and 39% in Pakistan (1995) to 56% in India (1992/93) and 66%
in Bangladesh (1995).32Adverse impact of such a high degree of malnutrition would be
considerable on the cognitive skills of children, affecting their educational performance
and impairing their future productivity.
The most striking example of women's disadvantage is the issue of millions of "missing
women" in South Asia (Dreze and Sen 1989). These countries have far fewer women
relative to men than other parts of the world, indicating discrimination in the form of
gender-selective child nutrition and health care. Intrahousehold discrimination in food,
health and education reduces survival chances of women. In industrial countries, for
instance, female life expectancy exceeds male life expectancy by about six years. Talcing
this six-year gap as the standard, the degree of female disadvantage in other societies can
be assessed—the smaller the gap the greater is the likely degree of female disadvantage.
According to this criterion, female disadvantage is worse in South Asia than elsewhere in
30 Data on maternal mortality rate (MMR) remain suspect for a number of
countries, however, as generation of such estimates requires a very large sample
survey, not easily affordable within the periodic monitoring arrangement. The
problem is magnified in the recent years in the face of rapidly declining
fertility rate in some countries of the region. Inconsistency in data is
particularly notable in case of Bangladesh (ranging from 440 to 850) , Nepal
(varying from -539 to 1500), and Sri Lanka (fluctuating from 30 to 240) across
various sources. Rather sharp decline in MMR in Pakistan during the eighties also
warrants further scrutiny.
31 Apart from maternal malnutrition, the precarious state of reproductive health
care was an equally important contributing factor to high maternal and child
mortality. Thus, in Nepal, births attended by trained health personnel constitute
7 per cent of cases. The corresponding figures for the other countries of the
region are Bangladesh--14%, Pakistan- lp%, India--34%, and Sri Lanka--94% (HOC
1999)-
32 Estimates for 1996 puts the Bangladesh national average for the underweight
children at 56%.
17
developing Asia. There is hardly any excess of female life expectancy over males in
Bangladesh, India, and Nepal, and only a slight gap of two years in Pakistan (ABB 1997).
In contrast, in the most advanced rcoimaik'n of Asia I long Kong, Korea, and Singapore
Irnuile lite expectancy is comparable with dial of die Industrial world.
The key message emerging from the preceding discussion may be summarized as follows.
Judged even by sheer economic terms, investment in women is surely one of the bestjudged investments with possibly highest social returns, one that immensely enhances the
future growth possibilities. Such "investment" must encompass a range of activities
leading to better education, better health, improved nutrition, increased job opportunities,
higher mobility, greater autonomy, greater authority, heightened civic activism, and higher
security. Whatever the degree of social progress that has occurred in South Asia during
the years of its Independence, it would not have been possible without the "agency" of
women. They were the silent vehicles of some of the most impressive social changes in
South Asia. But. they need to be "visibilised" more, and their "voices" need to be raised to
a much higher level, so that they are able to unleash, and be part of, a much more
dynamic, self-sustained and radical process of economic and social transformation.
Removing the barriers to fuller participation of women in all walks of civic life thus
represents one of tire most important routes to human poverty eradication in South Asia.
VI.
The Other Factors of Retrogression
Of course, there are other retrogressive factors in operation, dragging down the economy
and pulling behind the social progress. They include race and communal riots, ethnic
conflicts, militarisation, degradations of environment, criminalisation of politics, anti
democratic practices and gross violations of human rights. There are also problems of
"closed" mind-sets with perverse grounding in deepening aid-mentality and state-centric
mentality, breeding inefficiency and inequity corrupting the whole system of production
and distribution under state patronage in South Asia.
For South Asia, the debate of the moment is not between "reform" and "no reform", nor
even between "reform now" and "reform later". It is about the search for reforms, which
will have maximum impact in terms of long-term poverty reduction. But, centrally, the
debate is about the ways and means as to how to create institutional conditions to
support such reforms on a sustained basis.33 The importance of creating effective
institutions for sustaining even what one would readily categorize as equity-enhancing
market reforms (such as providing credit access to the poor) is increasingly becoming
apparent from South Asia's own experience as well as from the relevant international
33 The contrasting experience between Russia and China in managing the transition
towards market economy and, between Malaysia and Indonesia, in responding to the
Asian financial crisis,
points
to the critical
importance of enabling
institutions for managing and guiding the reform process. As argued earlier, the
process of institutional capacity building has been adversely affected by the low
level of human development, on one hand, and by the political economy constraints
to the removal of market distortions created by the old policy regime of inward
orientation, on the other. The persistence of these factors also explains why the
social results of the economic policy changes in the nineties with greater
reliance on outward-oriented development strategy have been rather minimal in
South Asia.
18
comparisons. Sustainable successes in development come only through policies that
promote faster human poverty reduction supplemented by rapid technological progress
in an institutional setting of humane governance and in an environment that promote
competition in the market place, locally, regionally and globally. This calls for an approach
balanced between the home and the world, the local and the global, the public and the
private, the collective and the self-interests. Arguably, this goes beyond the agenda of
conventional reforms of the re-distributive and market variety types, although there is
something to consider in both. This is not going to be a one-time exercise in reform, a
once-and-for all balancing act. Rather, in this approach, one needs to constantly learn the
new skills (and un-learn the old habits) of managing the ups and downs, the zigzags, the
darker and the brighter sides, the dialectics of the development process.
VII.
Conclusion
The discussions of barriers to faster human poverty reduction, as outlined above based
on South Asian experience, allow us to ground the possible policy choice on a firmer
conceptual and empirical basis. It leads to (he identification of the key policies that are
needed to overcome the constraints that inhibit the future potentials for faster human
poverty reduction. First, clearly, there is a need for pro-poor (equitable) growth policies
with particular attention to the problems of the poor areas and communities. Such growth
policies require the removal of distortions in the output and factor markets created by the
old policy regime of inward-orientation. The importance of continued economic reforms
geared towards outward-oriented development strategy needs to be seen in this light.
Second, new growth policies should be backed up by public social allocations favorable to
the poor, with right balance between physical (road, electricity, and communication) and
social investments (education, health, nutrition, and disaster-mitigation).
Third,
effectiveness of such allocations would depend a great deal on how they are managed
where the questions of good governance at central and local levels, on one hand, and
community7 ownership (and authorship), on the other, become critical arenas of design.
Good governance is not feasible without decentralization, but decentralized governance
must be accountable to the people. Community ownership of the policies and programs
via "social mobilization"—the strengthening of "social capital"—not only provides the
institutional basis for accountable governance, but also ensures its cost-effective
implementation and sustainability. Fourth, even "community" may have their own biases,
especially in South Asia, where the interplay of entrenched class, caste, and patriarchal
interests were instrumental to the exclusion of women from the public arena at large.
Policies and processes that discriminate against women, disempower them, need to be
tackled in their own rights. Such policies would be rewarding even from the view-point of
conventional criteria of development, since "visibilising" women in all spheres of
development and their empowerment will have strong growth and social multipliers.
19
SOUTH ASIAN DIALOGUE ON POVERTY AND HEALTH
15th to 18th November, 1999
Bangalore - India.
LIST OF PARTICIPANTS AS OF 15TH OCTOBER, 1999
THE SAARC COUNTRIES.
BANGLADESH
1
Dr. Abul Barkat,Economist, Professor of Economics, University of Dhaka, Dhaka.
2
Dr. Zafaruilah Chowdhry, International Peoples Health Council and Gonoshasthya Kendra. Dhaka
3
Dr.Bmayak Sen, Bangladesh Institute of Developmental Studies, Dhaka
. 4
Dr. Sharifa Begum, Senior Research Fellow, Bangladesh Institute of Developmental Studies, Dhaka
5
Dr. Naila Z Khan, Dhaka Shishu Hospital, Dhaka
6
Dr. Qasem Chowdhry, Executive Director, Gonoshasthya Kendra, Dhaka
BHUTAN
7
Bhutan representative - confirmation awaited.
INDIA
8
Prof. Debabar Banerji, Nucleus for Health Policies and Programs, New Delhi
9
Dr. Rajendra Ravi, Convenor, Lokayan, Centre for Study of Developing Societies, New Delhi
10
Ms. Mirai Chatterjee, Secretary, Self Employed Women's Association, Ahmedabad, Gujarat
SM)
:
'
1Dr. Devaki Jain, Economist, Bangalore, Karnataka
12 -,Dr. Mira Shiva, Head, Public Policy Unit, Voluntary Health Association of India, New Delhi.
■ 13
Dr. Mohan Rao, Center for Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi
14
J Dr. Ekbal, Chairman Health Sub Committee, Kerala Sastra Sahitya Parishad and Professor, Department of Neuro
Surgery, Kottayyam Medical College, Kottayam, Kerala
15
J Mr.Vimalanathan, New Entity for Social Action, Bangalore, Karnataka.
16
Dr. Prem Chandran John, Coordinator, Asian Community Health Action Network, Chennai, Tamil Nadu.
17- ^National Alliance of Peoples Movement India (Ms. Medha Patkar or alternative - confirmation awaited)
18
_pjg
Mr. Ravi Duggal, Center for Enquiry into Health and Allied Themes, Mumbai, Maharashtra.
Ms. Sujatha Rao, Joint Secretary for Health, Ministry of Health and Family Welfare, Government of India, New Delhi.
20 / Mr. R Gopalakrishnan, Secretary to Chief Minister and Coordinator, Rajiv Gandhi Missions, Government of Madhya
Pradesh, Bhopal, Madhya Pradesh.
21,/ Ms. Nimitta Bhatt, Trust for Reaching the Unreached, Vadodara, Gujarat.
MALDIVES
22.yMs. Fathimath Moosa Didi, Director General of Nursing, Ministry of Health, Male.
NEPAL
23
Prof. Mathura P. Shrestha, Chairperson, Nepal Health Research Council, Kathmandu
24Dr. Aruna Uprety, Kathmandu
<Dr. Indira Shrestha, the Coordinator of ENHR, Nepal Network, Kathmandu (observer).
25
PAKSITAN
26
.■ Prof. A. Gaffor Biloo, Chairman, Health and Nutrition Development Society, Karachi, Pakistan.
27
'■ Dr. Yousuf Memon, Department of Community Health, Aga Khan University, Karachi, Pakistan.
28
- Dr. Mohamed Ali Barzgar, Pakistan (observer) (confirmation awaited)
SRI LANKA
29
Ms Myrtle Perera, the Marga Institute, Sri Lanka Center for Developmental Studies, Colombo,
30
Dr. N.Sivarajah, Head, Department of Community Medicine, Jaffna University, Jaffna
31
Dr. Gaya Gamhewage, Director, Community Health, Lanka Jatika Sarvodaya Shramdana Sangamaya (Inc.), Moratuwa,
32
Mr. Susil Sirivardene, Janasaviya Trust, Colombo
OTHER REGIONS
FRANCE
Mr. Oliver Giscard d'Estiang, President, Business Association for the World Social Summit, Neuilly sur Seine
33
KENYA
34
Prof. Peter Anyang' Nyong'o, Member of Parliament, Nairobi
35
Mr. Charles Oyaya, Christian Health Association of Kenya, Nairobi,
PERU
3&r Dr. Oscar Ugarte, Centro de Estudios y Promocion del Dessollo, Lima
UNITED KINGDOM
37^Prof. Andy Haines, Department of Primary Care and Population Studies, University College London and Royal Free
Hospital, London
38 " Dr. Iona Heath, Inter Collegiate Forum on Poverty and Health, Royal College of General Practitioners, London.
39VMr. Des McNulty, Member of Scottish Parliament, Edinburgh
UNITED STATES OF AMERICA
40^Dr. W. Addington, President Elect, American College of Physicians, Chicago
WHO HEAD QUARTERS
41 '’'Mrs. Eva Wallstam, Director, Health in Sustainable Development, WHO, Geneva
42'-^Dr. John Martin, Deputy Director, Health in Sustainable Development, WHO, Geneva
43
~ Ms. Margareta Skold, IPHN Secretariat, Health in Sustainable Development, WHO, Geneva
WHO - SEARO / SAARC
44
Dr. Robert Kim Farley, WHO Representative to India, New Delhi.
45
' Mr. B.S.Lamba, Health For All Officer, WHO, SEARO, New Delhi
46'-Mr. Mohammed Hassan, SAARC Secretariat, Kathmandu.
COMMUNITY HEALTH CELL TEAM OF FACILITATORS
47x Dr. C.M. Francis, Consultant, Planning and Management, Community Health Cell, Bangalore
48
Prof. Mohan Issac, Professor and Head, Department of Psychiatry, National Institute of Mental Health and Neurological
Sciences, Bangalore.
49
Dr. Ravi Narayan, Community Health Adviser, Community Health Cell, Bangalore.
50
Dr. Thelma Narayan, Coordinator, Community Health Cell, Bangalore.
51
Dr Mani Kalliath, Team Leader, Advocacy, Catholic Health Association of India, Secunderabad
CONFIRMATION AWAITED
AUSTRALIA
52
Dr. Gillian Biscoe, Faculty, Monash University, Tasmania
GHANA
■A- 53
Dr. Nana Enyimayew, School of Public Health, University of Ghana, Legon-Accra
NORWAY
54
Dr. Else Oyen, Comparative Research Program on Poverty, Health and Social Policy Studies, University of Bergen,
Bergen
UNITED KINGDOM / AFRICA
55
Dr. Patricia Nickson, Senior Lecturer, Liverpool School of Tropical Medicine, Liverpool.
THE INTERNATIONAL POVERTY AND
HEALTH NETWORK
Secretariat located in the Department of Health in Sustainable
Development (HSD)
at the World Health Organization, Geneva
BACKGROUND
World Health Organization
20 Avenue Appia
CH-1211 Geneva 27
Switzerland
Fax: (41 22) 791 4153
Tel.: (41 22) 791 2111
THE INTERNATIONAL POVERTY AND HEALTH NETWORK
Secretariat located in the Department of Health in Sustainable Development (HSD)
at the World Health Organization, Geneva
BACKGROUND
Meetings on Poverty and Health
The Poverty and Health Network has formed as a result of a series of meetings which HSD
(formerly ICO) has organized or co-sponsored on the theme of poverty and health:
The first meeting in London 1995 was held in association with Action in International
Medicine (AIM). The "London Declaration" which summarized the concerns of the meeting,
was addressed to all institutions and associations of health professionals, and called upon them,
inter alia, to play an active role in reducing poverty and improving the health of populations in
their charge.
This declaration has stimulated worldwide activity by professional groups. Three examples:
the American College of Physicians hosted a symposium on international health at its annual
meeting in 1997; in the United Kingdom, several organizations of health professionals came
together to establish the Inter-Collegiate Poverty Forum, and in the Philippines, The Philippines
Academy of Family Physicians set up a task force on health and poverty, and is discussing with
the government how to expand the national coverage of primary health care.
The second meeting held in Maynooth, Ireland in 1996 co-sponsored by HSD and the
government of Ireland, brought together international and national NGOs who shared valuable
experiences of working with issues related to poverty and ill-health and in particular at
community level. The meeting focused on the role of NGOs in stimulating community-based
health initiatives, and on the need to think multi-sectorally. It recommended the promotion of
active partnership between ministries of health, NGOs and the community in targeting poverty
and its adverse effects on health status.
The third Congress in Baltimore in 1997 addressed itself particularly to the business
community and municipal authorities. Its purpose was to explore ways in which these
influential groups could use their special expertise and experience to tackle ill-health and poverty
among urban communities in both developed and developing countries. A major innovation
resulting from the Baltimore Congress was the concept of "Business for Health " championed by
progressive business leaders from Australia, Europe and United States. Business leaders agreed
to work with WHO to advocate and implement business policies aiming at social stability and
the reduction in poverty and inequities.
In December 1997 in London, two meetings on poverty and health were organized as a follow
up of previous meetings. These meetings led to the formation of the International Poverty and
Health Network, which saw as its role to advocate for health as a force of reducing poverty and
improving health development. WHO was requested to act as Secretariat to the Network.
Four main areas of priority for follow up were identified by the meeting:
1- Mobilising stakeholders
The aim of mobilising all stakeholders is to ensure commitment by local, national and international sectors,
business, health professionals, politicians and researchers etc to poverty reduction and improvement of
health of the poorest populations; and to ensure co-operation between the different sectors to achieve
results in priority areas. This would be done by:
• Developing a clear rationale for business involvement in poverty and health
• Involving new actors within business such as the Chicago commercial Club in the Network
• Identifying and involving stakeholders such as corporations, health associations, researchers, trade
unions, politicians etc. at local levels
° Developing country specific plans and mobilising key stakeholders
» Disseminating information and experiences.
o Writing a joint letter on behalf of the Network, to all the world’s health professional associations to join
and share the mission, including also letters to medical journals.
2. Involvement in Copenhagen plus 5 summit meeting
The aim of focusing on the Copenhagen plus 5 meeting is to engage the network in national and
international events and to bring health to the agenda of poverty reduction strategies. This will be done
by:
• Sharing information on what is already been undertaken by network members such as BUSCO
initiatives
• Disseminating the main outcomes of the 7 Summits to the Network members for their information
• Consultation of National Authorities by Network members on implementation of Copenhagen Summit
agreements
• The Network, through the secretariat (WHO) will endeavour to be part of the Prep. Coms of the Summit
and keep members informed about developments.
• An inventory will be established of Network members who have participated in previous Prep. Com
Meetings or at the NGO meeting at the Copenhagen Summit. This information will be sought through
a questionnaire by the WHO secretariat as well the network members such as Afri-CAN, BUSCO,
DESCO, and CHC.
■ The Network should become involved in different regions in influencing the agenda
• The network will be kept informed through-out the developments leading up to, and of the results
following the Summit meeting.
During 1998, the Network gained momentum and a series of activities were undertaken by
members: In several African countries, participatory analyses were undertaken on socio
economic determinants of ill-health and community strategies developed in response to the
situation. In the U.K., the IntercoUegiate Forum on Poverty and Health contributed to the
Independent Inquiry commissioned to look at inequalities in health; conferences were planned
in the Philippines on the role of health professionals in poverty reduction, and in the U.K. on
health of adolescents living in poverty. An increasing number of people expressed interest in, and
joined the network. Certain encouraging changes within WHO have given the Network further
impetus.
The new leadership of WHO has firmly placed poverty eradication and health as a key to
development at the top of WHO’s agenda. In her "inaugural address" to the World Health
Assembly in May, Dr. Gro Harlem Brundtland WHO’s Director General declared:
“We must speak out for health in development, bringing health to the core of the
development agenda. That is where it belongs, as the key to poverty reduction and
development underpinned by the values of equity, human dignity and human rights".
In order to consolidate the work of the Network, agree on key objectives and a plan of action,
and strengthen participation in the network of people and organizations in the South, a meeting
of a small advisory group was convened in Nairobi and Kisumu , Kenya during November 23-26,
1998.
Statement of Purpose of the Network:
One of the important elements of the meeting and for the continuing development of the
network, was building consensus amongst the participants, of the Statement of Purpose of the
Network. These were agreed on as follows:
^IriWhatiisThe Imternatibrial'Pdveftyrahd Health Netw.o'rk?ri^^^sHs^j^sxfsig^ri
'^^fi&lPHtij^^S^^d^i3fenqf^orlc^p.^pl<ari3...drgani^tiohgft6m3)ealt^&usii^s^
j^hf6i^'uonfblirtlie;mostreffecuves^proaches?andgsol'utidlfsfT6rtlh~eSffi7ih~^dverfy^
,
- - - - - -I - ■ -- ■ -- ■
~
■ , . . .,
—
•^eradicattomp51icies=strategigsandiacaons==^™^==srtrzgps~~^^^^^=
~
_ ■*
■ ■ «■■ ■»■■■■ .<—■?•....... —....... . .... ■ ’■
=^eoplesmd3j'rg^satibn'slffiat=msIutoanfl~u'en^JpoIic^Eana^cfibh=fo,^pfoteEt:-fandf:
j^a^^^ffiSS^S^gffie^^dfs^of^ffi'p^cin^emplfasisrom tifeip^d^S^hiall;
r“£.COUDtljeS
~
? -1 . — —...... . , ; r. Wi'ri
....... . . .
-. —— -** • .ww— — ~r~-. .
........
.-A/T6rint¥gratef[healihf into .poyerty/eradicatiori '-policies ■. and fstrategiesU;pronioting':
Ujcommunity-pSinership.ahd intersectoral.acti_on,.-as.a:means .to achieve effective and;
^[j^tinaWejresults.
■r
~
..f
■_
3. Information and Research
The meeting recognised the need and importance of collating, exchanging and disseminating information
regarding heath in poverty reduction in order to strengthen local and national and international capacities. This
would be done through:
• Collection of research results, experience, interventions relating to poverty and health
• Exchange and dissemination of information - newsletters, Internet, existing networks, publications, national
regional and international summits and conferences, journals, political arenas, media etc.
• Storage and retrieval of information experiences : creation of data base; publication of catalogue
8 Shared methodology ( share and disseminate the most successful as well as unsuccessful participatory
methodology.
• Promote evidence based research
» Focus on community involvement in research
3.1
Capacity building
- For health professionals and people of other disciplines working with communities.
- Skills development for members in areas of management and governance, research skills and advocacy
methodologies
- Producing workable CB models of addressing poverty and health currently developed by Network
members such as:
• Community based partnership model at TICH.
• Community determined health and development at the Pan African Institute
• Media training for community IPPHCN (S.Africa)
» Management for poverty and health -Ceara BRAZIL
4. Strengthening the Network development
Efforts will be made to strengthen and expand the network through the following:
• Communication and exchange of information
- The language issue was raised and a concern expressed that the network also disseminate information in
French and Spanish through its newsletter and reports from meetings etc. It was proposed that the newsletter
be published three to four times a year.
- It was agreed that a central web site be created for the Network and that a list of members' names and
addresses be included. This web-site could also link up with other useful web sites both of members and
other organisations and associations, which could be of use to members. Once national and regional network
are established, these could also link up with the web site. However, since not all members have access to
the Internet, this information should also be available through other means.
• Identifying and Mobilising the Network Resources
- Creating a data base on existing resources within the Network which clearly informs on the capacity and
resources of each member. This information should be disseminated through the Internet and on the web site
and accessible in hard copy for those who are not on the Internet.
- Creating /linking up with networks at a national and international level
Your response is IMPORTANT
Establishing a network is not an objective in itself. Its value lies in what it is able to achieve
in addition to what each member is doing individually. The network therefore depends on the
creativity, ideas and active participation of its members in the development of joint activities and
collaboration. As facilitator of the network, HSD will be in regular contact with the members,
soliciting input to the newsletter, enquiring about activities and involvements of the area of
poverty and health, and sharing ideas and thoughts. We will be counting on you!
We are very keen that you will be an active member of the network and we very much hope
that you will accept the challenge and commitment which this involves. We would appreciate
if you would manifest your interest in being a member of the network by returning the enclosed
membership form. This will help us consolidate the network and enable us to start working
actively on information sharing and news from network members.
Please return the attached form to:
Julia Jameson, HSD
World Health Organization
Avenue Appia 20
CH 1211 Geneve 27
Suisse
Tel: (41 22) 791 2558
Fax: (41 22) 791 4153
Email: jamesonj @ who.ch
INFORMATION ON MEMBERS/ MEMBER INSTITUTIONS
1. Type of membership (individual or institutional)
2. Name of individual member / institution:
3. Contact person (institution):
4. Address: (including telephone, fax and e-mail)
5. What are the goals, objectives, areas of activity/speciality and methods of working of
your institution?
6. Publications
7. What tools could you/your institution share with the network?
8. How would you like to receive the letter in future?
•
By hard copy
•
By e-mail (as an attachmant or within the text - please specify)
•
I will download from the internet
9. Comments and suggestions for making the network a success
THANK-YOU I
SOUTH ASIAN DIALOGUE ON POVERTY AND HEALTH
Pre-Dialogue Opinion Survey-A Preliminary Compilation
o
This compilation of the pre-dialogue Opinion Survey collates key perspectives,
concerns and suggestions from 21 participants out of 50 who responded.
o
The objective was to identify the range of concerns and perspectives; identify
broad areas of consensus as well as differences, on issues and determinants in the
complex links between poverty leading to ill health; ill health leading to poverty;
the global, regional and national structural determinants of poverty and inequity in
health; and the growing synergy between poverty alleviation, development
programmes and health care initiatives and services.
o
This compilation is a check list and background to the discussions. Responses
have been classified into groups that are related. Notwithstanding differences in
perspectives among respondents because of the differences in situation and
experiences in different countries and regions of the world, we believe that the
compilation would be a useful stimulus for participants to reflect upon. .
o
Perhaps you would like to tick some of them! Are these issues, responses relevant
to your own country experience? Your own region experience? Are these
consistent with your own perceptions about the global situation and global
issues? Do you find the initiatives listed out to tackle poverty and ill health
relevant to your own country / region? Do you agree with the responses for
priority initiatives at global level?
o
What you tick at the beginning of the dialogue will be what you already know!
What you tick at the end of the dialogue will be ideas / perspectives that have been
presented by others which have convinced or challenged you! There may be many
others not in the list. You may wish to add as you go along.
o
This compilation has been an evolving process since participants have been
sending responses well beyond the deadline. We welcome these and will do a
more integrated compilation for the Proceedings of the Dialogue. For the present,
we hope it will serve the purpose of being a ‘collective’ stimulus!!
o
We thank the following particularly for their contributions which have been
integrated into this compilation:
© Prof. Abul Barkat and Dr. Sharifa Begum from Bangladesh;
O Ms. Fathimath Moosa Didi from Maldives
© Dr. Mathura Shrestha and Dr. Indira Shrestha from Nepal;
© Dr. Barzgar from Pakistan;
© Dr. N. Sivarajah and Ms. Myrtle Pereira from Sri Lanka;
© Prof. D. Banerji, Dr. Prem John, Dr. Mani Kalliath, Mr. R. Gopalakrishnan, Ms.
Nimitta Bhatt, Dr. Mohan Rao, Ms. Shilpa Pandya and Mr. Ravi Duggal from India;
© Dr. Iona Heath, Prof. Andy Haines from UK;
© Ms. Patricia Nickson from Congo/Ivory Coast; and
© Mr. Kim Forley and Mr. B.S.Lamba from WHO.
Bangalore, 12th November 1999
CHC Organising Team
INTERNATIONAL POVERTY AND HEALTH NETWORK
SOUTH - ASIAN DIALOGUE.
PRE DIALOGUE QUESTIONNAIRE.
Collation of Responses
A. Key issues in order of priority linking poverty and ill health regionally.
S.No
Issue
1
Lack of commitment ofpolicy makers for equitable development and distribution
Lack of political will to implement social policies
Lack of political will to tackle wider determinants of health
Lack ofaccess to health and nutrition and lack of awareness
Lack of access especially transport related
Poor access to- and opportunities for- social welfare services leading to ill health
Inaccessibility (cultural, economic, etc.)
Lack of access to health care / lack of income leading to ill health
Lack of state funded, people oriented health planning and programmes focusing on marginalised people
Inadequate spread of public health services
Linkage of ill health to social opportunities
Inadequate understanding of poverty
Inadequate understanding of determinants of ill health
Inadequate appreciation of the links both at policy and curriculum (medical education)
Poor understanding of links between poverty and ill-health
Redefinition of challenges and solutions
Powerlessness ofpeople
Power structure I social structure against the marginalised
Non-participatory democracy / elitist policies
Lack of choices for social and economic investment decrease capacity for empowering women
Gender issue in health and poverty e.g., female literacy etc.
Poverty and ill health related to breakdown of families
Need for decentralised models - panchayati raj
Lack of comprehensive government health infrastructure
Break down of public health systems
Institutional development building for health education for new challenges
Limits of current delivery model
Deficient health services to marginalised communities
Malgovemance of health systems
Inequitable distribution of health resources
Exploitation and marginalisation of the poor
Caste - system and lack of education as a cause of marginalisation of the poor
Social exclusion
Reversal of income inequalities
III health causing decreased human capacity
Burden of ill health on poverty
Capacity building in health to improve productivity and alleviate poverty
Lack of educational opportunities among girls and women
Poor education among children linked with poverty
Illiteracy causing ill health
Role of education in links to poverty and ill health
2
3
4
5
6
7
8
S.No
Issue
9
Onslaught ofStructural Adjustment Programmes(SAPs) and Global economic policies - decreased social
sector spending
Exclusion of marginalised in every sector due to SAPs
Lack of integration ofplanning and programming of health services within overall frame work to bring
10
2
11
12
13
14
15
16
17
18
19
20
21
22.
23.
about socio-economic development.
Too much concentration on health promotion rather than tackling socio-economic deprivation.
Lack ofsimple and relevant research focusing on determinants of ill health
Lack of health data by socio-economic categories
Lack of nutritional data by socio-economic categories
Civil war
Civic instability
Links of behaviour, life style and poverty.
Low expectation of poor people
Poor pattern of rural development - lack of access to.skills and technology to alleviate poverty
Poor nutrition
Water for drinking and agriculture
Environmental degradation
Increasing degradation of the environment
Decline in labour productivity
Employment - both lack and under
Means of livelihood
Large scale under-employment
Repeated disasters
Housing and environment
High teenage pregnancy
Large, unregulated private health sector
B.
Three key issues in order of priority that are important globally for the links between poverty
and ill health.
S.No.
Issue
1
Widening economic gaps between rich and poor between and within countries.
Skewed utilization of global resources
Gaps due to discrimination,. Social inferiority , geographic and political and environmental factors
Impact of globalisation on the non market goods important to poor ie health education and welfare.
Response of globalisation on double and triple burden of diseases
Impact of privatisation of health care
Impact of globalisation and privatisation on human development
Discriminatory aspects of World Trade Organisation and International Monetary' Fund exploiting
poorer countries
Unequal trade
Partisan and often hegemonistic role of IMF I WB etc
Reduction of global health inequalities to be made part of IMF / WB agenda
Prevailing monopoly of global knowledge / technology / resources
Global opportunities unevenly distributed between countries and people
Globalisation increasing inequalities within and between countries
Rethinking SAPs
Unequal distribution of global resources
Structural readjustment
Unequal distribution of wealth/resources
2
Poverty eradication through pro poor land/ investment policies.
Supporting inter-sectoral action
S.No
3
4
Issue
Economic development through human development
Poor nutrition
Hunger and malnutrition
Malgovernance ofpublic health
Catalysing decentralised management of health sector through targeted funds
Focusing on issue of poor sanitation
Governance of health programmes in accordance with Alma Ata declaration
Universal access to healthcare as a right not pushed adequately
Debt burden of the heavily indebted poor countries
3
Cancellation of international debt
International debt
Educational disadvantage
Lack of education
Strong evidence based data linking poverty and ill-health
Promotion of locally appropriate models of health care
Regional militarisation and arms race engineered by first world diverting limited national resources.
Health impact assessment of international arms trading
Ecological changes and environmental degradation in third world caused by industrial pollution by
Trans-national Corporations(TNCs)
Ecological degradation and environmental pollution
Environment
Subservience of WHO to dictates of C-7
Increasing TNC/Donor control over health programs
dismantle WHOs global initiatives and relate global actions to local actions
shift in perspective of personnel of WHO / international development agencies
Multinational Corporations
Norms of basic preventive and curative services to be available to all people
Equity and sustatinability
Threat to human security - economic / health / cultural / environmental
Manmade disasters wars , arms race etc.
National instability
Efforts to minimise vulnerability of the poor to health-related shocks
Monitoring ofprovision of basic social services
Lack of physical infrastructure
Promoting value ofsocial mobilisation and spirit of community particiaption in development activities.
Po werlessn ess
Lack ofpolitical commitment
Lack of commitment to PHC
Employment
Unemployment
Low status of women
Population explosion and its socio-economic and environmental consequences
Globalisation only of capital, but not of labour
5
6
7
.8
9
10
11
12
13
14
15
16
17
18
19
20
22
23
C.
List of key initiatives in order of priority to tackle issue of poverty and ill-health regionally.
S.No.
I
Issue
Vigorously pursuing poverty eradication programmes
Reduction of child poverty
Improved support in both cash and kind to support vulnerable young families
S.No.
Issue
Poverty alleviation programs - Samrudhi Program
Special measures for the extremely poor
Provision of credit and asset and technical know-how to the poor
Providing comprehensive health care emphasis on women’s health, at subsidized cost.
Strengthen school programs, provide nutrition education promotion of home gardening
Reorientation of PHC program to make it more intersectoral and relevant
Ensuring good governance of public health
District level health planning to be aggregated from panchayat levels
Integrating health programs
Institutional support through a “basic health services guarantee scheme
Rejuvenate the health services by reviving the managerial physicians and rolling back the generalist
administrators
Integrated socio-economic development
Social security programs
take steps to prepare local bodies to take over health activities
Creating mechanisms to assure universal access to health care irrespective of the capacity to pay
2
4
3
4
5
6
7
8
9
10
11
12
Giving teeth to grassroots democracy / empowering panchayati raj
Strategy and programs for empowerment of the marginalised people
Empowerment of people to assert their health and development rights
Encouraging investments in health
Increased public health expenditure
Increasing health expenditure
Investment in public health services
Higher allocation of resources to the health -sector
Provision and analysis ofhealth impact of various loans and investments in all sectors
Macro-economic policy that ensures equitable distribution of fruits of growth into investment in
education / health /nutrition
Campaign to ensure that all public service quality assurance programmes include measures of
inequality
Increasing educational attainments
converged human developmental action on female education
investment into education and welfare
Implementation ofpro- poor health policy
political articulation of Health as a human right in order to redefine the national health agenda
Bring health into the mainstream of development
Increasing awareness of the linkages between poverty and ill health
Raise awareness about health impact of poverty
Operationalising of the growing realisation that the ultimate goal of all the development is human
health and well-being
All sectors committing to develop holistically ensuring all-round development
Social action oriented towards gender justice and equality
Involve community based NGOs , Career guidance and vocation training
Civil society initiatives through NGOs
Creating broad alliance of peoples movements for countering exclusionist and authoritarian tendencies
in the country
Working with people and organising them
NGOs to concentrate their work among the poor communities.
Resolution of conflicts and cessation of war
Local, national and regional stability
Reduction in militarism and spending on arms
Identify the poor and prepare special programmes for their upliftment
S.No.
Issue
13
Research competence ought to be developed to determine ways of most effective use of limited
resources - concept of cost-recovery to be abandoned
Locality specific and problem-based participatory research to enable all levels of society to make
informed decisions
Advocacy to enforce social, political, legal, and ethical responsibility and obligation to implement
various declarations etc
Refugee doctors to be integrated into the health services(specific to Britain)
De-addiction of nations from foreign aids and grants
Encouraging small economic enterprises.
Micro credit schemes especially directed to women
Expand health infrastructure and access
Identifying root causes of powerlessness
Increasing women's education
Stopping privatization
Employment guarantees for the poor
Environmental regeneration programmes
Saving lives, opportunity for all, work ofsocial exclusion unit
Tackling fuel-poverty
Work of the Food Standard Agency
14
15
16
17
18
19
20
21
22
23
24
25.
26.
5
27
D.
Regulation ofprivate health sector
List of key initiatives- in order of priority- required globally to tackle the issue of poverty and
ill-health.
S.No.
Issue
1
Assign top priority to poverty eradication policies
Priority to be given to all governments to assist the poor and backward comm.
75% of international aid for next 2 yrs to be given to poor comm. In a country
Implement ways and means of minimizing acute vulnerability of poor
Sustain policy focus on poor regions and poor people
Provide financial and technological support for development of services like health and education for
the poor
Pro-poor and pro-disadvantaged programs
More funds to development infrastructure and social sectors.
Resolve governance issues ofpublic health
Promote community participation
Do not fund vertical health plans
Fund horizontal health programmes at grassroots level
Conceptualise ways to integrate vertical health prog. Within overall perspective of dealing with poverty
and ill-health
Halt / reverse privatisation of health services
Return to HFA through PHC
Inter-organisational dialogue - between WHO / UN agencies/ NGOs / WB etc
Functional unity of concerned International Organisation
Positive and enhanced role of UN organisation and Bretton Woods inst. In human development
Democratisation of global decision making e.g., equal weightage in World Bank I UN Security Council
etc.
Soul-searching by international agencies to understand why they strayed
Heart-searching by international agencies on reason for failing to develop competence in health systems
research
Global alliance esp. of civil societies
2
3
S.No.
4
5
6
7
8
Issue
Global alliance for human capacity and resource building
Health Impact Assessment methodology for the World Bank and IMF
International commitment for universal access to health care
Debt relief
writing off national debts of developing countries
Moratorium on debt servicing
Waiving unjust third world debt
Cancellation of International Debt
Greater commitment of resources by first world for health and poverty initiatives in third world
Just trade practices
Developing mechanisms to correct unjust trade relationships
Removing inequity in research and development in the world
Free and unhindered flow of information
Essential national health research ( ENHR)
Pro-equity and sustainability development models
Integrated socio-economic development
Prioritisation of human development over economic development
Advocacy that human development is a prerequisite for sustainable development
Mobilisation of resources and political will for implementation of UN summits
Dialogue / coalition building / solidarity - towards sustainable development - including south-south and
north and south
75% of poorer community in a country should have access to potable water and good sanitation
To replace dominance cult and subservient mentality with a liberation paradigm
Alternative perspectives to address consequences of globalisation
Dissemination of information or. linkages between poverty and ill health in lay and scientific media
6
9
10
11
12
13
14
15
16
17
18.
Dissemination of success stones successful in alleviating poverty and ill health
Encouraging and supporting initiatives for development of decision making abilities e.g., in Panchayati
Raj Institutions
Gender sensitive social development
Micro- financing as it has impacts on health equity
Problem ofpowerlessness needs to be researched
Community based health care
Traditional remedies and home care
Strengthening equity initiatives of WHO
Bottom up rather than top down planning
International Control of the Anns Industry
Greater commitment of develop countries to reduce /rationalise their consumption patterns
7
SOUTH ASIAN DIALOGUE
HSD comments on specific parts of the report
The comments are based on the draft report of 4.8.2000 and references that are made to
page numbers are also based on the same draft.
On a general note, the main body of the report is long and could be shortened and tightened
up in order to provide the reader with a summarized overview of the main issues presented at
the meeting. Suggestions have therefore been made to restructure the report and to transfer
some parts of the text to annexes. We think this will ensure the flow of the discussions. It also
needs further work by a good editor, to make it reader friendly.
•
Page 1: first bullet - HSD is the department (not cluster) of Health in Sustainable
Development
•
Page 2: Is the box a quote - would it not be possible to start with a quote that sets the
report off in a more positive way, highlighting the opportunities that now exist to focus on
the issues of health and poverty, commitments that have been made and the role of the
civil society in putting pressure on governments to follow through their commitments...etc.
and that this is one of the reasons the meeting was organized.
•
Page 3: Statement - if HSD is mentioned, the WHO representation should also include
representatives of the Regional and country offices.
•
Page 5: Signatories of the statement could go out - it is not necessary since all the
participants are listed in the participants list.
•
Page 8: Preparation and process of dialogue - there is too much detail in this part and a
one paragraph summary would be enough.
•
Page 8: The data in the table is too old and could be replaced by more recent numbers.
•
Page 9: the quote from Mark Twain is over simplistic and does not reflect that we are
trying to create a dialogue environment. New language is needed I
•
Page 10: Under the heading "Some of the key learning experiences from community
visits" subheadings and regrouping the bullet points would be appropriate and would
make reading easier. Obvious headings include: social participation, health services.
governance...
v
•
Page 12: Information on the communities visited could be transferred to an annex.
•
Page 13: John Martin : text should be changed to : He assured the participants that WHO ,
“ is already actively involved in developing this approach”.
•
Page 13 table : again... somewhat old data
•
Page 14 : Banerji - “he noted with concern that most people seem to assume a simplistic
relationship between health and poverty" - what does this mean? It would be good to
V
spell out.
•
Page 16: Mathura Shresta's part - text too much like the tape recordings — it needs to be
summarized into main points.
Could we take out the bullets in this and the following presentations in this section - bullet
points become very tedious to read after the first three... it would be good if all the bullet
points were summarized as in the case of Chowdhury's presentation.
Page 17 : Abul Barkat has been given too much space if both diagrams are included. It
throws off the balance between presenters.
Page 19 : if statistics are used, as in the chart, it would be good to quote UNDP or other
official sources.
Page 20: Section 6 - if possible, again, it would be more interesting reading if the bullet
points could be spelled out and summarized in a paragraph or two under each heading.
Otherwise you risk losing the reader.
Page 23: Who/what is the source of quotes in the boxes?
Page 23: section 7 again- too many bullet points - the format of 7.4 and 7.6 is much
better! Need for consistency in all the subheadings.
Page 25.: box 1 - source?
Page 26: the box is not very useful since nothing is mentioned about the process... in this
case study it was the approach that was interesting!
Page 29: box of Skolnik - surely it is not the poor people that should be considered a
disaster but the extent to which poverty is rampant!
'v
Page 29 - WHO and Health which document is referred to? Is it the EB document on
poverty and health - the information in the paragraph is not clear.
Page 30: Under same heading WHO and health : Use present tense. Take out bullet 2
and 3 (starting “WHO was trying to make a difference....” And "WHO was under
pressure.." Seattle ) and replace with the following text:
WHO is actively participating in global processes, such as follow up of UN summits
and joint activities on health in poverty reduction with other UN agencies, the World Bank
and Development partners. WHO is also developing relationships with major trade bodies
(WTO, UNCTAD). In discussions with them, WHO is promoting policies to ensure that
trade agreements work to protect the health of people, especially the poor and
vulnerable.
N
WHO is establishing dialogue with a broad range of actors, including civil society, the
private sector and the pharmaceutical industry. This process of listening and reaching out
to others offers a good opportunity also for countries in the South, to make sure their
perspectives are reflected and their voices heard in the Organization.
Page 30-31: section 9.3 Some implications of international collaboration - the text
under this sub heading does not correspond to the heading... since it is about one
agency, World Bank projects in one country, India... and not at all about international
collaboration. It does not seem logical to keep it here under this heading. This section
could be summarized into a few paragraphs.
Page 34 -38: Section 10 - Action for change - some initiatives and emerging strategies
in Asia. Since this section is descriptive (and at times too detailed) it could come into an
annex - unless some actions for change could be summarized or drawn out from the
case studies.
Page 39 -40 section 11 is also very descriptive and could become an annex, unless we
present the case studies as a learning experience as has been done for 11.6 Devaki Jain.
The mere description of a case study is not so useful. 11.8 Towards an IPHN action plan
could remain somewhere in the main text since it does reflect a discussion that took place
‘
:'
. ,•••5
at the meeting. The PHA could also stay in the main text as this was discussed and
action encouraged.
Report of the South Asian Dialogue
Zo
<Ct~1 p
Subject: Report of the South Asian Dialogue
Date: Thu, 23 Nov 2000 15:03:55 +0100
From: petersa@who.cb.
To: sochara@blr.vsnl.uet.in
-Irt ^0
CC: martinj@who.ch, skoldm@who.ch. villare@who.ch
Dear Ravi and Thelma,
After an extended period of silence due to new, demanding challenges
in our work, I am writing to you with regard to the Report of the South
Asian Dialogue. We discussed it recently in a management meeting, to agree
on a way forward.
Many thanks for all the w’ork that you and your team have put into
developing the report. We feel that it reflects well the proceedings of the
meeting, although we do have a few comments on specific parts of the report
which we have annexed to this message. We recognize that getting such a
report together has been both a time consuming and a rather complex task
since you have been working from the recordings of the, meeting. We started
our discussions here by re-looking at the target audience and the potential
use of the report. In its current format, the report is probably of most
interest to those who participated in the meeting and we would therefore
like to suggest that it be distributed to those who were involved in the
dialogue. Since a year has now passed, we will not make it a formal HSD
publication and we suggest that distribution could be done by e-mail.
However, should CHC wish to make it into a document and send it out to
participants, this would also be fine - we would see this as CHC's
contribution to the process of dialogue and follow-up.
ch
One of the main objectives of the meeting was to promote dialogue,
exchange of ideas, experiences and strategic approaches to health in poverty
reduction. I am sure that we all agree that these goals were very well
reached. The news we hear about preparations for the PHA also seems to
reflect that the dialogue and mobilization of many of those present, has
continued after the meeting. We are delighted to hear this!
In our view, a
report from the meeting is therefore not so much a tool for change for
people who were not present, but rather an aide memoire for those who were
part of the dialogue. I am sure that the report will be a welcome reminder
of what participants committed themselves to in terms of activities and
joint efforts in the area of health and poverty.
Having said that, it would be important for us all, I imagine, to
have a 4-5 page summary of the meeting, which reflects the main
issues/messages that came out of it. We need to be able to share this
information with our donors and others that are interested, and in the
dialogue with colleagues, policy makers, and other decision-makers, and also
to paste it on our web site. Since CHC have had the responsibility for
writing the report of the meeting, I would request that you also develop
this summary.
Many thanks once again to the team at CHC for all your hard work,
both in making the meeting a success, and in the production of the report.
Greetings from us all in HSD.
Eva Wallstam
Director
Health in Sustainable Development
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COMPLETE LIST OF MATERIAL DISTRIBUTED DURING THE
SOUTH ASIAN DIALOGUE
ON
POVERTY AND HEALTH ,
,,.t
Communication I:
1- Pre Dialogue Opinion Survey.
2. Health and Development: Key Note Address by Prof. Amartya Sen. World Health
Assembly, May 1999.
3. Poverty' and Health - Regional Issues : South- East Asia. WHO-SEARO.
I? ;■ >
p_
Communication II
1. Tentative Pre-final Program of Work.
2. List of Confirmed participants
3. Community Visits - a note.
Communication III (Background Papers).
1. Report of Consultation on Equity and Health in SEARO, Trends, Challenges and
Future Strategies (Executive Summary).
2. Making Health a Public Agenda - Indira Shrestha and Mathura Shrestha.
3. Tackling Health inequalities in Primary Care - Editorial in BMJ by Liam Smeeth and
Iona Health
4. Poverty and Ill-Health : Physicians can and should make a difference - From Annals
of Internal Medicine by Michael McCally, Andrew Flaines et al.
5. Final Report of meeting on Policy Oriented Monitoring of Equity in Health and
Health Care, Geneva, September 1997. (Executive Summary)
6. Civil Society Initiatives - Human Development in South Asia, 1997 Mahbub ul Haq.
‘
Contents of File Distributed at Dialogue
1. The Framework of the Dialogue
2. The Final Program
3. The List of Participants
4. Participants Profile I
5. The Community Visits - Objectives (?)
6. Some notes on Community Visits
7. The Summary of Opinion Survey
8. Suggested Questions for the Group Discussions
9. Learning from the Community - A Checklist of Parameters for the report
10. A Bibliography of the reading material received for the dialogue
11. A CHC Pamphlet
12. An International Poverty and Health Network (IPHN) Note
13. A note of WHO-HSD (not distributed)
14. To Our Health - The News letter of WHO - World Health Assembly Special 1999
(Pgl&3}
15. An Invitation card for Cultural Program and Special Dinner on 17lh November, 1999
D-X —
Otic—
16. Symposium Paper I - Poverty , Disease and National and International Power
Structure - The case of India by Prof. D. Banerji, India
17. Symposium Paper II - Poverty and Development Paradigm - Peoples Perspective by
Prof. Mathrua Shrestha and Dr. Indira Shrestha, Nepal
18. Symposium Paper III - Equity in Health Care - A Formidable Challenge for Sri Lanka
(synopsis) by Ms. Myrtle Perera
19. Symposium Paper IV - Crisis in Governance of Public Health System in Bangladesh :
A Challenge of Humane Governance by Dr. Abul Barkat (Synopsis)
19. (a) Full Paper
20. Cartoon
21. Health and Poverty in War by Dr. N. Sivarajah, Sri Lanka
22. The Poverty of Amartya Sen by Mr. Anil Agarwal, India
23. An Intergrated approach to Community Health : The Sarvodaya experience in Sri
Lanka by Dr. Vinya Ariyaratne, Sri Lanka
24. A report on The Rajiv Gandhi Missions - Government of Madhya Pradesh
25. Strengthening Community based Health Care in Madhya Pradesh through
Decentralised Management of Health Services by Mr. R. Goplakrishnan, India
26. Peoples Campaign for Decentralised planning the Health Sector in Kerala by Dr. B.
Ekbal, India
27. A new Health Policy for Health Sector reforms by Mr. Ravi Duggal, India
28. Poverty and Health : a universal abuse of Human rights by Dr. Sunil Kaul, India
29. A note from Mr. B.S. Lamba
30. Relevance of Ideas and Mass Mobilisation for the Removal of Poverty and Inequality
by Dr. Devaki Jain, India
31. Poverty and Health; Reaping a richer Harvest - a book notice
32. Special Issue - Health and Equity - Health for the Millions, New Delhi
33. Special Issue - Community Health: Search for a new Paradigm - Health Action,
Secunderabad
34. A Map / pamphlet on Bangalore
/4 S’-iiA.-ii?.
Handouts
1. Inaugural Session and Symposium - program and speaker profile
2. Social Development initiatives in Pakistan By Dr. Yousuf Memon - Symposium
Presentation (Synopsis)
2. (a) Complete set of OHPs
3. Explaining Slow Progress in Poverty Reduction in South Asia by Binayak Sen,
Bangladesh
4. Globalisation and the Health of the Poor; beyond the Rhetoric of Health for all by
2000 by Dr. Prem Chandran John, India
5. Comments on "Case Study of World bank activities in Health Sector in India". Community Health Cell, India
5. (a). Set of OHPs of Dr. Ravi Narayan's presentation
6. The World Bank Perspective - Set of OHPs presented by Dr. Richard Skolnik
7. Poverty and Health: Some Experiences from the Self Employed Women's
Association (SEWA), India
8. Peoples participation in Maldives - pamphlet
8. (a). Booklet
9. Peoples campaign for decentralised planning - OHPs of presentation by Dr. B. Ekbal,
India
10. Intersectoral Action - OHPs of presentation by Dr. Andrew Haines
11. Identification of Poverty and Health Risks - OHPs of presentation by Dr. Patricia
Nickson, Congo and Ivory Coast
11. (a) The Cultural context of PHC by Dr. Pat Nickson
11. (b) Sustainability of Health Care in a Situation of Insecurity (case study of
Congo) by Dr. Pat Nickson
12. Health and Human Power Development: Issues and Concerns - OHPs of presentation
by Dr. D.K. Srinivasa, India
13. Role of Private Medical Practitioners - OHPs of presentation by Dr. Nimitta Bhatt,
India
14. Basic Minimum Needs Program - OHPs of presentation by Mr. Barzgar, Pakistan
15. Group Discussion Notes:
15. (a) Ill Health Leading to Poverty- Gr I / II
15. (b) Pauperization of Women - Gr I / III
15. (c) Disaster, Poverty and Health - Gr I / V
15. (d) International Donor Agencies - Gr- II /1
16. Draft Statement of the South Asian Dialogue on Poverty and Health
Handouts (Others)
17. Major Areas of Concern on WHO "Health of all in the 21st Century" Draft Document,
Voluntary Health Association of India, India
18. Draft Health Policy 1999 - Government oflndia
19. Peace and Poverty - Article
20. Poverty in Poverty Analysis—
21. The Twain the Most Americans Never Meet - email
22. Poverty - A Major Constraint in the Community Care of Orphans in Zimbabwe by
Drew RS et al, Zimbabwe
23. A Violation of Citizens' Rights : The health sector and Tuberculosis by Dr. Thelma
Narayan, India
24. A Solid Base for Health by M.A. Barzgar, Pakistan
25. Kofi Annan's Facts - Photocopy of News paper article
26. Articiles contributed by Dr. Naila Z Khan
26. (a) Lead'Poisoning and psychomotor delay in Bangladeshi children
26. (b) Mortality of urban and rural children with cerebral palsy in Bangladesh
26. (c) Effect of an equine movement therapy program on gait.... A pilot study
26. (d) Destroying our childrens' brains with lead in air
26. (e) Recognising child maltreatment in Bangladesh
26. (f) Best resource use for disabled children
27. Amartya Sen on development and Health - Interview in To Our Health - May 1999
28. Link - Bulletin of ACHAN - June 1999
29. Orissa Cyclone Appeal - Action Aid
30. Publication lists - WHO - task force on Health Economics
30. (a) Publication List - WHO - "Macro economics Health and Development"
PRE FINAL MAUSCR1PT
SOUTH ASIAN DIALOGUE
15th - 18th November, 1999
Bangalore, Karnataka, India
j ;■ -i r; /Q P ' /
Or
Organised by
Community Health Cell, Bangalore;
International Poverty and Health Network, Advisory Group;
WHO-Health in Sustainable Development, Geneva.
JULY, 2000
. World Health Organisation
2000
SI.
No.
Title
Page
1.
EXECUTIVE SUMMARY AND A STATEMENT OF SHARED
CONCERNS AND COMMITMENTS
1 -5
2.
BACKGROUND
.6 - 7
3.
PREPARATION AND PROCESS OF DIALOGUE
8-9
4.
LEARNING FROM THE COMMUNITY VISITS
10 - 12
5.
INAUGURAL SESSION AND SYMPOSIUM
13 - 19
5A
INAUGURAL SESSION
5B
POVERTY AND HEALTH IN SOUTH ASIA : CRISIS AND CHALLENGES
14 - 19
6
HEALTH AND POVERTY : EXPLORING THE LINKAGES AND
EVOLVING A FRAMEWORK FOR DIALOGUE
20 - 22
13
6.1
Socio-economic Deprivation and ill Health
20
6.2
6.3
6.4
III health leading to Poverty
20
Feminization of Poverty
20
Globalisation and Health
21
6.5
6.6
Poverty, Ecology and Health
Disaster, Poverty and Health
21
21
6.7
Key initiatives to tackle issue of poverty and ill health regionally
22
6.8
Key initiatives globally to tackle the issue of poverty and ill health
22
7.
GLOBAL / REGIONAL NATIONAL CONCERNS IMPACTING ON
POVERTY AND HEALTH
23 - 25
7.1
Globalisation and health
23
7.2
WTO and Health Agenda
23
7.3
7.4
Intellectual property rights and commodification of Health
24
Privatization and Health
24
7.5
Breakdown of Public Health System
25
7.6
Neglect of Traditional Systems of Healing
25
7.7
Conflict, Poverty and Health
25
8.
POLICY ISSUES FOR EQUITY IN HEALTH AND POVERTY
REDUCTION
8.1
Strengthening Civil Societies
26
8.2
Pre toting Intersectoral Action
26
8.3
Tac ding powerlessness through empowerment
26
8.4
Politics of Health Policy implementation
27
8.5
8.6
Identifying research priorities
27
Role of Private Practitioners
27
8.7
Health Humanpower development
28
8.8
Basic Minimum Needs approach
28
9.
HEALTH AND POVERTY ERADICATION - THE ROLE OF
INTERNATIONAL AGENCIES : PERSPECTIVES AND CONCERNS
9.1
World Bank and Health
9.2
WHO and Health
29-30
9.3
Some implications of International Collaboration : A Caution
30-33
26 - 28
29 - 33
29
SI.
No.
Title
Page
10.
ACTION FOR CHANGE : SOME INITIATIVES AND EMERGING
STRATEGIES IN SOUTH ASIA
34 - 38
10.1
Poverty and Health : Experiences from SEWA, Gujarat, India
10.2
Talking Poverty and Powerlessness for Community Health - Sarvodaya Shramadana
Movement, Srilanka
34-35
10.3
Peoples Participation in the Maldives - South Asia Poverty Alleviation Programme,
Maldives
35-36
10.4
People's Campaign for Decentralised Planning - Kerala Shastra Sahitya Parishad,
Kerala, India
36-37
10.5
Basic Minimum Needs Programme for Primary Health Care - The Nowshera
Project, North West Frontier Province, Pakistan
37
10.6
Decentralised Management of Community Based Primary Health Care : Towards a
Community Health Guarantee Scheme - Madhya Pradesh, India
37-38
10.7
Poverty and Child Disability - Case Study, Bangladesh
11.
SOME EXPERIENCES AND PERSPECTIVES FROM BEYOND THE
SAARC REGION : South - South and South - North dialogue
1 l.l
11.2
Health consequences of the uninsured in the U.S.
Inter-collegiate forum on Poverty and Health. U.K.
39
11.3
11.4
Partnership with Business for Global Health
Listening to the People
39
11.5
Dialogues on Poverty and Health tn Bangladesh
40
11.6
Some lessons from recent experiences of South-South dialogue
40
11.7
The People’s Health Assembly, Dhaka 2000 A.D.
11.8
Towards an IPHN Action Plan
40
41
12.
STRATEGIES FOR ACTION : An Agenda for 2000 AD and Beyond
12.1
Strategies for Change : Local / Community
42
12.2
Strategies for Change : National Level
42
12.3
Strategies for Change : Regional / SAARC Level
Strategies for Change : WHO Level
42
12.4
43
12.5
Strategies for Change : International Donor Agency Level
43
34
•
38
39 - 41
39
39
42 - 43
APPENDICES
A.
B.
C.
D.
List of Participants
Programme of Work
Community Visits - a Note
List of Background papers and reports circulated as Background (Bibliography)
i-v
vi - xi
xii - xiii
xiv - xvii
(This proceedings is an overview of a very comprehensive, analytical and intense dialogue where many
participants contributed greatly through written papers and very active reflection, discussions and sharing of
experiences. Due to constraints of the size of the planned proceedings an attempt has been made to
summarise the key issues from every session focussing on 'what was said' and not always 'by whom'. An
editorial prerogative to amalgamate presentations, to convert some into case studies and box items etc., has
been proactively followed. A larger publication to do greater justice to all the contributions to the dialogue is
planned)
(Proceedings as of4.8.2000. Further editing in progress)
in
1. EXECUTIVE SUMMARY
<■ A South Asian Dialogue on Poverty and Health was organised by Community Health Cell
of the Society for Community Health Awareness, Research and Action, Bangalore in
collaboration with the Advisory Group of the International Poverty and Health Network and
the Health in Sustainable Development Cluster of the World Health Organisation, Geneva jlzj
from 15th - IS111 November, 1999 at The National Institute of Advanced Studies, Bangalore
(India).
<• The dialogue was attended by 48 participants of whom 33 came from the South Asian
Region^including Bangladesh, India, Maldives, Nepal, Pakistan, Sri Lanka and National
Regional Networksjand 15 came from other countries like Kenya, Congo, France, United
Kingdom, Peru, USA and International agencies including WHO-Geneva, WHO-SEARO
and the World Bank.
<■ The pre-dialogue interactive planning process included three communications from the
facilitating team in Bangalore; a series of background papers and reports; and a pre
dialogue opinion survey among the potential participants including a programme planning
survey.
<■ The Dialogue began on the 15th with Community visits to Health, Development and Poverty
alleviation programmes organised by voluntary agencies (NGO’s); a medical college and a
Corporate sector initiative. The aim of the Community Visits was to provide an opportunity
to the participants to observe and listen to the experiences of people living in poor and
marginalised communities and to learn how they cope with the situation, as well as what
they think of the initiatives of government and non governmental agencies. The focus of
these projects included bonded child .labour; street children support; slum outreach;
indigenous people; people with disabilities; rural women’s development and a community
development initiative of a corporate sector.
<> At the end of the day there was a session at which the participants shared their group
learning experiences from each visit
<> On 16th there was a special Public Symposium on Poverty and Health in South Asia :
Crisis and Challenge at which experts from India, Bangladesh, Nepal, Sri Lanka, Pakistan
and WHO-HSD presented their perspectives and concerns to a larger number of invitees.
<> The 3 - day dialogue consisted of sessions on the following themes :
. Inaugural Session
Orientation to Dialogue and Group Inventory on expectations and issues; Global, Regional
and National Concerns impacting on Poverty and Health; Health and Poverty Eradication
Perspectives of the World Bank and WHO; Health and Poverty Eradication : Action
initiatives and strategies — local, national, government and NGO; Policy issues for Equity in
Health and Poverty Eradication; Experiences from the South and the North; Action Plan 2000 AD and beyond.
<> The 3 day dialogue was also interspersed with small group discussions on the following
themes :
Socio-Economic Deprivation and Ill health; Ill health leading to poverty; Feminization of
Poverty; Globalisation and Health; Poverty, Ecology and Health; Disaster, Poverty and
Health; Strategies at local / community level; Strategies at National Level; Strategies for
SAARC Region; Strategies for WHO/IPHN; Strategies for International Donor agencies.
<> Finally by the end of this intense dialogue - both through small group level and plenaries, a
statement of shared concern and collective commitment emerged including an agenda for
suggested action at various levels.
Globalisation and Health of People
The health care of the marginalized has always been a peripheral issue to the
ruling structures, more particularly in Asia and other developing nations.
What we term as 'malignant neglect1 has led to a state where the poor have
no access to even the most basic of health services and this is reflected in the
shameful health statistics relating to them. The current processes of
globalization and liberalization have compounded the problem. Especially
affected are the already marginalised : the rural poor, the landless outcastes,
the indigenous groups of people and among them, selectively women.
Tangible proof already exists that the ill effects of continued neglect
combined with the recent processes of globalization, have already selectively
affected the marginalilsed. It is difficult to directly fight against global
economic powers. All is not lost. There are specific roles that the voluntary
sector can play capacitate the poor now to build up their inherent power and
their solidarity through the formation of peoples' organizations which will,
then, articulate their needs and place them in public eye. There are of course
specific roles for organizations such as the World Health Organization, which
are crucial as well. 2000 A.D. is a defining moment in the history of people's
struggle for health since that is the year which will celebrate the empty
rhetoric of 'Health For AH'. Our concern is not health for all but rather,
health for some, i.e., the poor of Asia. Our concern more specifically is to
help the poor develop coping strategies that would help them deal with the
looming threat of globalization.
- Prem John, ACHAN
2
Statement of Shared Concerns and Commitments of the South Asian Dialogue
on Poverty and Health
We, the participants of the South Asian Dialogue on Poverty and Health, gathered,
at the National Institute of Advanced Studies, Bangalore between 15th and 18th
November, 1999
t
Coming from the participant countries Pakistan and Sri Lanka;
Bangladesh, India, Maldives, Nepal,
With representatives of World Health Organisation - Health in Sustainable
Development;
The International Poverty and Health Network (IPHN) Advisory Group; and
Facilitated by the Community Health Cell, Bangalore,
Are Concerned with :
©
The deepening social and economic inequalities between and within countries and
peoples;
©
The adverse consequences thereof on health across the globe;
•
The nature and direction of change in health sendees and health policy;
0
The major policy shifts in diverse sectors impacting on health such as agriculture
and industry;
©
The broad policies of globalization, economic liberalization and privatization
under the aegis of international financial institutions which are weakening state
commitment to the health and development of large sections of the people who are
poor;
©
The health sector reforms comprising a package of programmes involving
cutbacks in public sector health expenditure and strengthening of vertical donor
driven programmes which have considerably eroded the reach and effectiveness
of already weak public health systems.
©
The unregulated growth of the private sector which has undermined poor people’s
access to health care services and exacerbated regional, class and gender
inequities;
©
Widely prevalent hunger and a heavy burden of preventable communicable
diseases,
©
Trafficking of women and children and growing sex tourism,
,
© Increasing military expenditure for internal and external conflicts, and
nuclearisation in the region which have all meant a neglect of the social security
sector
© Increasing loss of traditional knowledge bases, skills, values and culture;
Q Pauperisation
deterioration.
of
indigenous
peoples
3
and
women,
and
environmental
We recognise :
©
The strength and potential of poor people themselves, especially women, who
through community based efforts, peoples movements and local governance
systems address these problems;
©
The positive role played by the state including its public health interventions in
improving health status of the people;
@
The solidarity among different global, regional, national and local networks for
health and development.
We Declare our Commitment to :
©
Continuous improvement of the health of our people and to the reduction of socio
economic disparities and deprivation.
©
Complete overhauling of the public health system and health services of our
countries with democratisation, decentralisation and collective decision making,
with affirmative action for the poor and the vulnerable.
o Equity as focus in all our programmes - social, economic, health and development
so that disparities will be reduced.
©
Greater transparency and accountability in all our programmes.
© Empowerment ofpeople, especially women, children and disadvantaged groups.
•
Working towards peoples movements for removing unnecessary ill-health and
eradicating poverty .
o
Working towards the formation of an informal network of all people interested in
improving the health of the people and removing poverty, and thus support
strongly the evolving International Poverty and Health Network
© Promoting the generation offull employment of all people with living wages.
• Efforts to mobilise all sectors of human endeavour, such as education, agriculture,
shelter and employment which are the determinants of health
©
Tackling malnutrition in our countries with efforts to improve nutrition and ensure
nutrition security.
©
Working towards greater resource allocation for health and meeting basic needs
ofpeople.
© Reducing rising costs of medical care which are already high, with indications of
becoming increasingly out of reach of the poor.
© A continuing emphasis on primary health care and community health action.
© Organising communities to make community diagnosis and decide what is to be
done.
e Consciously striving to reduce pollution of air, water and soil, which adversely
affects the quality of living.
© Mobilising public opinion in the West, such that no harmful effects are brought to
South Asian countries, including toxic waste and obsolete industries.
©
Careful study of the effect of globalisation on health and socio-economic
deprivation.
4
4c
© Ensuring full access to information and work to have the right.fnformation. We
request the governments and international agencies to help us in getting valid and
reliable information.
© Ensuring clean and humane governance in the countries of regions protecting the
health and well being of the poor and deprived.
J
•
Finally we conclude that :
© Health is a. fundamental human right and an integral part of human development.
©
The values of Equity, Social Justice; Empowerment; Humane Governance must be
the comer stone of all our efforts towards Health For All.
©
We shall work towards a movement for removing ill health and eradicating
poverty which will address efforts at local, national, regional and global level
tackling the broader determinants of ill health and the inequitous global systems
so that they can be changed to support the Health For All Goal.
(■ ■!
'
'■
Signatories of the Statement
1
. Dr W. Addington
(United States)
25
Dr. Naila Z. Khan
(Bangladesh)
2
Prof. Debabar Banerji
(India)
26
Dr. Robert Kim-Farley
(WHO_SEARO)
3
Dr. Abul Barkat
(Bangladesh)
27
Dr. B.S. Lamba
(WHO_SEARO)
4
Dr. Mohammed All Barzgar (Pakistan)
28
Dr John Martin
(WHO)
5
Dr. Sharifa Begum
(Bangladesh)
29
Mr Des McNulty
(United Kingdom)
6
Ms. Nimitta Bhatt
(India)
30
Ms. Aodiiti Mehtta
(India)
7
Prof. A. Gaffor Biloo
(Pakistan)
31
Dr. Yousuf Memon
(Pakistan)
8
Dr. Zafarullah Chowdhry
(Bangladesh)
32
Dr Ravi Narayan
(India)
9
Dr. Qasem Chowdhry
(Bangladesh)
33
Dr. Thelma Narayan
(India)
10
Ms Fatimath Moosa Didi
(Maldives)
34
Dr. Patricia Nickson
(Congo / Ivory Coast)
11
Dr. Richard Drew
(United Kingdom)
35
Mr. Charles Oyaya
(Kenya)
12
Mr. Ravi Duggal
(India)
36
Ms.Shilpa Pandya
(India)
13
Dr. B. Ekbal
(India)
37
Ms. Myrtle Perera
(Sri Lanka)
14
Dr. C.M. Francis
(India)
38
Dr. Mohan Rao
(India)
15
Mr Oliver Giscard d’Estaing (France)
39
Dr. Rajendra Ravi
(India)
16
Mr. R. Gopalakrishna
(India)
40
Dr. Mira Shiva
(India)
17
Prof. Andy Haines
(United Kingdom)
41
Prof. Mathura Shrestha
(Nepal)
18
Dr Iona Heath
(United Kingdom)
42
Dr. N. Sivarajah
(Sri Lanka)
19
Dr. Mohan Isaac
(India)
43
Ms Margareta Skold
(WHO)
20
Dr. Devaki Jain
(India)
44
Dr. D.K. Srinivasa
(India)
21
Dr. Prem Chandran John
(India)
45
Dr Oscar Ugarte
(Peru)
22
Mr. Geo Jose
(India)
46
Dr. Aruna Upreti
(Nepal)
23
Dr. Mani Kalliath
(India)
47
Fr. John Vattamattom
(India)
24
Dr. Geethani Kandaudahewa (Sri Lanka)
48
Mr. Vimalanathan
(India)
5
" 1■
2. BACKGROUND
< An International Poverty and Health Network, was created in December, 3997, following a
series of conferences organised by the WHO on the theme of Health and Poverty in recent
years. The Network brought together an increasing number of Health professionals*
NGO’s, Community groups, academics and researchers, government officials at various
levels, and representatives from the business community - all of whom were either already
engaged in activities designed to reduce poverty and improve the health of the poor and the
marginalised or disadvantaged or who were beginning to recognise the need for such
interventions. WHO was requested to act as the Secretariat for the Network.
< During 1998 the Network gained many new members and initiated some activities which
included
►
Participatory analysis in six African Countries of the socio economic determinants of
ill health and community strategies developed in response to the situation.
>
Contribution by the Intercollegiate Forum on Poverty and Health to the Independent
Inquiry Commissioned to look at inequalities in health in the UK.
►
An opinion survey among participants on issues of concern on Poverty and Health in
their countries and regionally and globally in the context of the evolving IPH Network.
This was facilitated and collated by Community Health Cell, Bangalore, India.
<■ And finally an important meeting of a Small Network advisory group in Nairobi and
Kisumu, Kenya from 23-26, November, 1998
>
consolidate the work of the Network;
>
agree on key objectives and priorities; and
►
strengthen participation in the network of people and organisations in the South.
< The Kisumu Meeting explored the links between Health and Poverty; reflected on the
challenges in addressing the problems of poverty and ill health; identified the stakeholders
of the Network; identified opportunities, strengths and weaknesses of the Network; and
outlined four main areas of priority for follow up ■
►
Mobilising stakeholders
►
Involvement in Copenhagen plus 5 Summit meeting
►
Information and Research
►
Capacity building
It also decided to make efforts to strengthen and expand the Network through
>
Communication and exchange of information
►
Identifying and mobilising Network resources
►
Creating and linking up with networks at a national and international level.
6
The most important element of the Kisumu Meeting was the reaching of a Consensus on the
Statement of Purpose of the Network.
What is the IPHN Network?
The IPHN is a world-wide network of people and organisations from the fields of health,
NGOs, business, government and society p in general who exchange experiences and
share information on the most effective approaches and solutions for health in poverty
eradication, policies, strategies and actions.
Who is it for?
People and organisations that wish to influence policy and action to protect and
improve the health of the world's poor, with particular emphasis on the poorest in all
countries.
What is its aim?
To integrate health into poverty eradication policies and strategies, promoting
community partnership and intersectoral action, as a means to achieve effective and
sustainable results.
Source : IPHN Advisory Group Meeting Report
Kenya, November, 1998.
<■ At the Kisumu Meeting apart from the representatives of the African Region there were five
representatives from South Asia, who included a Health NGO from Gujarat, India; a
representative of a National Health Network - India; the Coordinator of the Rajiv Gandhi
Missions of the Government of Madhya Pradesh, India; a policy researcher from the
Bangladesh Institute of Development Studies; and another from CHC, Bangalore, India.
After the meeting, during the follow-up phase, the idea to host the next meeting of the
advisory group in South Asia evolved and got linked to a larger South Asian dialogue.
=> The Society for Community Health Awareness, Research and Action (also known as CHC),
Bangalore agreed to facilitate a dialogue bringing together a diverse range of resource
persons, members of networks; and many who shared the same concerns and objectives as
the evolving IPHN Network from the South Asian Region.
7
?
PREPARATION AND PROCESS OF DIALOGUE
<> The planning of the dialogue was facilitated by a very interesting interactive and
participatory process which included three rounds of communications with all potentia)
participants.
<> The first round included a note on IPHN; the proceedings of the Kisumu meeting; the first
two newsletters of the Network; a copy of the keynote address by Professor Amartya Sen
entitled Health in Development (WHO Assembly, May 1999); a booklet entitled Poverty
and Health - Regional issues : South East Asia from WHO-SEARO; and a Pre-dialogue
opinion Survey which elicited opinions on the theme as well as programme planning.
<> The second round included a tentative programme of work at the dialogue; a tentative list
of participants to share an idea of the diversity and potentiality of the dialogue; and a short
note on Community visits with six options.
The third round included further background information on the dialogue; and six
background papers which included a WHO-SEARO consultation on Equity; a WHO
Geneva consultation on Policy oriented monitoring of Equity; three background papers
from potential dialogue participants on the themes - Making Health a Public Agenda
(Indira and Mathura Shrestha); Tackling Health inequalities in Primary Care (Licon
Smeeth and Iona Heath); Poverty and Health : Physicians can and ^should make a
difference (Michael Me Cally and Andrew Haines et al); and the Civic Society Initiatives
section of the Report on Human Development in South Asia, 1997.
< Finally a fourth round just a week before the dialogue included a first collation of the pre
dialogue opinion survey; a short perspective note of the whole programme; and a
bibliography of all the materials (papers and reports) received for the meeting.
<> Most of this interactive process was earned out by a sort of email networking and post
wherever necessary and the general response of the participants was so enthusiastic that
the foundation for an interesting and significant dialogue was laid.
Distribution of the world's poor 1985-90
Number of poor in millions
Region
1985
1990
1.051
1.133
South Asia
532
562
East Asia
182
169
Sub Saharan Africa
184
216
Middleeast & North Africa
60
73
East Europe
5
5
Latin America & Caribbean
87
108
All developing countries
Source : The World Development Report, 1992
8
The Agenda
Through the interactive pre dialogue process the following Agenda evolved for the South
Asian Dialogue :
* Poverty is a global issue. There is both concern and increasing evidence that poverty and
inequalities in health care are increasing the world over, in poor and rich countries; in
developed and developing economies. These trends are directly linked to and are further
exacerbated by the growing forces of liberalisation, globalisation and privatization (LPG
phenomenon)
* There is increasing evidence particularly from South Asian experience that socio
economic-political and cultural determinants of poverty and ill health are not only local
and national, but increasingly regional and global.
* Hence any action directed only at local or country level will have little impact on the
he :1th status and situation of inequity. There is increasing urgency to understand the
gi )bal determinants of poverty, inequity and ill health and to tackle them at that level as
well. There is need for analysis and action at all levels - global, regional, national and
local.
The Participants
The Participants were carefully selected to ensure that the dialogue was between scholars,
researchers; policy makers, administrators, NGOs, health and development activists, civic
society, peoples movements and the business sector. There were experts from both
government and non-govemment backgrounds. The dialogue was multidisciplinary and the
group included doctors, nurses, public health professionals, economists, social scientists,
epidemiologists, management, and other disciplines.
Participants also represented
multisectoral and multi level backgrounds to enhance the potential of the dialogue.
Mark Twain on Equity
"Who are the oppressors? The few : the king, the capitalist and a handful of
other overseers and superintendents. Who are the oppressed? The many : the
nations of the earth; the valuable personages; the workers; they that make the
bread that the soft-handed and idle eat."
"Why is it right that there is not a fairer division of the spoil all around? Because
laws and constitutions have ordered otherwise. Then it follows that laws and
constitutions should change around and say there shall be a more nearly equal
division."
9
4. LEARNING FROM THE COMMUNITY VISITS
On 15th November, 1999 the Dialogue began with the programme of Community Visits and all
those participants who had arrived by then were taken in six groups to dialogue with the poor
and marginalised in six community settings. ’
Th e aim was to
<
visit the community and observe;
<
listen to the people living in the community especially the poor and the marginalised,
regarding their experiences ofpoverty and ill health;
<
learn how they cope with the situation and what they think of existing governmental and
non-governmental initiatives in health care and poverty alleviation; and
<
identify how the Network and other agencies could strengthen community initiatives at
local level through support to governmental/non-governmental initiatives.
The six projects selected also provided the participants to understand the diversity and
complexity of poverty and ill health by focussing on marginalised groups which included poor
rural women; bonded child labour and school dropouts; street children; children from slums
and or urban poor; indigenous people (schedule tribes); and people with disabilities.
/
The initiators of these projects included non-governmental organisations; a department of
community health of a medical college; a corporate sector supported rural development
initiative.
The field visits included dialogue with the community; visit to project initiatives; a shared meal
with the community and a visit around the community wherever feasible. During the visits the
links between ill health and poverty in each of these special situations was also probed.
The decision to start the South Asian dialogue with the Community Visit was to ensure that the
participants keep the grassroots realities of the poor and marginalised in their minds as the
dialogue proceeded so that practical suggestions rooted in their reality would emerge. It was also
part of a decision of IPHN advisory group that listening to the people from the host region was
to always be an important part of a dialogue.
At the end of the day all the Participants gathered at NIAS to share their learning experiences
from the Community visits.
Some of the key learning experiences from the Community Visits were :
1. People perceived lack of food and employment as the most important problems of their rural
community.
2. Urban poor cited land, housing, water and absence of sanitation facilities as the major
problems they face. Food and health were not seen as equally important.
.
' In the absence of good quality and accessible health care provided by government, the poor
3.
were forced to use private health sector even though this increased their economic burden
and contributed to indebtedness.
10
P
“
4. Health interventions must include not only curative but also preventive and rehabilitative
aspects especially when work is among people with disabilities in a community setting.
Income generating activities and vocational training must be complementary to the whole
effort.
5. Women's health needs to be addressed in ways that empower women. Income generating
activity and micro-credit schemes can be an instrument of such empowerment. Health
programmes can be implemented and monitored through the active involvement of women’s
groups. They can be empowered to address their human rights issues through appropriate
local bodies.
6. Many bonded labour choose to remain within the exploitative system because of inadequate
economic opportunity if they come out of it. Hence existing legislation against it continues
to remain ineffective.
7. People often vote in elections not for particular programmes or needs but because of family
and other loyalties to a particular party that can run through generations.
8. Bribery' and corruption in the system were common but with greater community organisation
and awareness, some resistance was beginning to be offered by the poor and marginalised.
9. For urban slum children and street children, a vocational orientation to educational initiatives
makes the programme more effective and sustainable. For rural children summer camps and
child to child and child to community awareness building initiatives using songs and other
interactive approaches can be great fun.
10. Integrated development of indigenous people and other marginalised groups provide not only
income generating activity but also maintain a sense of community and tradition and involve
women.
11. Problems such as alcohol use I abuse in the community need a multipronged approach.
There is need for legal control and bans. There needs to be peoples collective action to
impose these bans socially and women are often willing to organise around the issue.
Deaddiction programmes need to be complementary.
12. Community meetings should be held in open places and transparent so that everyone
interested in the issue being discussed can observe the proceedings and are encouraged to
contribute.
13. The community should be trained in participatory learning processes which contribute to
effective discussion and decision making processes.
14. For models of intervention to be replicable and sustainable - two features are important i.e.
leadership and the increasing involvement of volunteers from the community.
15. Joint collaborative action by NGOs, business groups and public authorities can support
success stories and positive experiences of change in urban disadvantaged communications.
16. Corporate sector involvement in rural development can often be motivated by drawing upon
cheap labour to do ancillary jobs at a cheaper rate. The challenge will be to change this to a
fundamental motivation to improve economic lives of the local people rather than just reduce
' cost of production. However the economic spin offs and the contribution to tackling
unemployment should not be underestimated.
11
THE COMMUNITIES VISITED
1.
JEEV1KA, Anekal
An organisation working with bonded labourers (Children) and School dropouts who work in
hotels, bars, restaurants and brick factories.
The children are identified through a network of village animators who intervene and dialogue to
put these children through a bridge course at Jeevika, which is a rehabilitation method to put them
back in Schools. They also organise unions of previously or former bonded labour in different
villages around Anekal to demand their rights and benefits from government schemes.
2.
APSA, Bangalore
The Association for Promoting Social Action is a voluntary organisation which works with children
mainly from slums; street children; children sent into cities as migrant labour, bonded labour, or rag
pickers and even those sexually abused or in prostitution.
The NCO runs residential centre providing accommodation and elementary education and
vocational skills for children rescued from distress, a child line; sensitising police personnel to the
needs of these children; slum outreach programmes; de addiction programme for street children
addicted to drugs; and a college student sensitization project.
3.
CRAM RAKSHE, Kodahalli
A Rural Development project of Sree Ramana Maharshi Academy which started in October 1994.
The focus is on Lambanis, indigenous people in Kodihalli, who are now marginal farmers and
agricultural labourers.
The four main activities of this project are agriculture and development; organising womens and
farmers groups / clubs; health education and income generation activities.
4.
A.P.D., Bangalore
The Association for People with Disabilities is an organisation working with People with Disabilities
for many years. It is an institution with multi faceted activities including health and medical
rehabilitation, education, vocational rehabilitation, community awareness and prevention
programmes. In more recent years, it has begun community based rehabilitation initiatives in
various slum outreach programmes to support parents of disabled children and teach them home
based skills to cope with caring for people with disabilities.
5.
Mugalur Women's Development Project
A project initiated by the faculty of the Community Health Department of St. John's Medical
College, Bangalore where women are encouraged to form women's groups to empower themselves
with inputs from the department. These include home based economic activities including micro
finance and credit cooperatives and other income generating activities. This provided women
greater economic security, status and control over their own lives.
6.
Meadows, IRDT and Snehalaya, Hosur
Titan Watch Company which is a Tata's Corporate sector initiative is involved in rural development
activities in the Hosur region through the support of small community based units for assembly of
watches, metal bracelet manufacture and manufacture of clocks provided to self help groups of
women facilitated by local ngos.
Meadows rural eneterprises is a self help group of women, 180 of whom work in the village unit of
Midugarapalli. IRDT is another ngo runs another unit which provided support to 40 people from
surrounding villages who include orphans, destitutes, widows and the disabled.
Snehalaya is a home for people with locomotor disabilities which also provides outreach
physiotherapy and support to disabled in the village itself apart from undertaking awareness
building programmes for polio, HIV/AIDS and other diseases.
All these three groups are supported by the corporate sector.
12
5. INAUGURAL SESSION AND SYMPOSIUM
5 A. INAUGURAL SESSION
The Inaugural session on 16th November, 1999 set the framework for the meeting.
®
Dr. Thelma Narayan, Coordinator of CHC (local host and facilitating organisation), in her
welcome to the participants emphasised the need to understand the complex relationship
between Poverty and health in the South Asian region and the urgent need to design
appropriate policy measures to reduce poverty and ill health. ‘Above all’ she pointed out
‘what we need is solidarity in supporting a movement for poverty reduction and
improvement in the state of health of the poorest sections of our society”.
®
Dr. Chandrashekara Shetty, Vice Chancellor of the Rajiv Gandhi University of Health
Sciences of Karnataka State began his inaugural address by first emphasising that the right to
health should become a fundamental right. He argued that “poverty is not created and
sustained by the poor. It is the system ofpolicies and governance that creates and sustains
poverty.
Good governance can be achieved only with people’s participation and
accountability”. He suggested that the process of change required good leadership; health
partnership between government, ngos and the business community; setting priorities that
focus on fulfilling unmet needs of the poor; stressing preventive health care significantly.
®
the Principal Health Secretary of the Government of Karnataka,
pointed that the State of Karnataka was the second state in the country to work on a state level
human development index. He stressed the needfor both poverty alleviation and health care
Mr. Abhijit Sengupta,
strategies to address regional disparities and inequities and argued that we need at
government levels a sort of corporate strategy which shifts from a structural focus to a
socio-cultural framework.
®
Dr. Robert Kim Farley, Regional Director of WHO SEARO, assured the participants , of
WHO-SEAROs full involvement in the Poverty and Health initiative and he stressed the
"need to place health on the top of country agendas and making access to health care a
fundamental right. Dialogue was the first step always".
®
Dr. John Martin of WHO-Health in Sustainable Development Cluster in Geneva, stressed
that “health cannot be left to the health sector alone and that there was urgent need to
explore ways of protecting the health of the poor”. He assured the participants that WHO
-would-be-pleased to participate in developing this nc'tt approach.
Percent Share of the Poorest 20% of the World Population in Global Opportunity
% of Global Economic
Activity
1960-70
1990
Global GNP
2.3
1.3
Global Trade
1.3
0.9
Global domestic investment
3.5
1.1
Global domestic savings
3.5
0.9
Global commercial credit
0.3
0.2
Source : The Human Development Report, 1993
13
S
5 B. POVERTY AND HEALTH IN SOUTH ASIA : CRISIS AND CHALLENGES
®
The Public Symposium on 16th morning chaired by Dr. Devaki Jain an Economist,
deeply involved in Women’s policies and co-chaired by Prof. D.K. Srinivasa, Medical
Education Consultant to the Rajiv Gandhi University of Health Sciences, provided ap
overview of the crisis and challenges of Poverty and Health in South Asia.
®
Dr. Devaki Jain, in her introductory remarks, observed that South Asia is a very special
case with examples of both amazingly successful models of change and the most
wretched figures in Poverty and underdevelopment. She emphasised that “wearing
womens lens” i.e., reflecting on the whole Poverty and ill health keeping the women's
perspective and women as central focus provides the best means for understanding the
development dilemmas.
<>
began his keynote address on a very sombre note by
highlighting that the world was in a deep crisis and that the gulf between the haves
and the have-nots was increasing. His primary concern was that “the voiceless
Prof. D. Banerji,
must fight and must be heard. The struggle of the poor is going to be very long
and grinding. ”
He also noted with concern that most people seem to assume a simplistic relationship
between health and poverty. Most people who hold such simplistic relationship do not
recognise the “socio-economic factors underlying improvement in health”.
He argued that both national and international power structure did not allow realisation of
the key messages of the Alma Ata declaration, namely that (a) Health is a fundamental
right
(b) people should be the prime movers of the health care system (c) there should
be a social control over health policy and (d) co-operative efforts should be encouraged
to achieve better health.
He deplored the fact that even the most sensitive developmental economists have not
given due attention to the adverse effects of globalisation and structural adjustment
programmes on health. He further added that “health care system has deteriorated and
has been decimated because of the bureaucratic and techno-centric approach adopted
during the last decade.
He suggested the following to address effectively the current crisis in health:
®
allow access to health care for the poor;
®
rebuild health care system, which includes “decentralisation of health care
system” and “simultaneous rejuvenation ofpublic health institution (for training
of health professionals, not for bureaucrats)
®
merger of Family Welfare and Health Departments; and
®
encourage multi-disciplinary policy research.
14
Poverty, Disease and National and International Power Structure :
The Case of India
>
"Poverty in whatever way it is defined, has a number of deep human dimensions in the
form of the way it affects individuals and groups. It also has deep cultural, social and
human ecological implications. Over and above it has roots in the history, international
politics and trade, geography, economy and power relations which determine the political
setting.... At the very least these dimensions must be kept in mind while making
judgements and conclusions about individual countries and populations. Very often this is
not done".
►
'Persistence of poverty and ill health and other social and economic maladies is due to the
failure of those who command authority to translate the concept of 'purposive
intervention' (Myrdal) into action (including intervention for improvement of health status).
This is essentially a political question".
>
'.... properly designed health services to alleviate the suffering of the poor, due to health
problems have a positive role in preventing people from going below the 'poverty line', in
increasing their capacity to fight for their causes, increasing their capacity to earn more and
in acting as entry points or a 'lever' to stimulate development in other poverty related areas
of action'.
>
'There is a tendency for ambivalence among international agencies and economists who
do not mention the devastating impact on the poor peoples of the world of the World Bank
/ IMF inspired programmes of globalisation, structural adjustment programmes and cost
recovery for social services from the people and encouragement of the private sector in
health; the World Trade Organisation had added to this predicament of the poor by
importing many trade regimes which affect their lives’.
"The task of alleviating poverty disease syndrome is thus an uphill one. The deprived
have to struggle hard to impel the ruling elite to make judicious social allocations for this
purpose. In India the modest gains made during the first two decades after Independence
were eroded by the over riding priority to resource allocation for implementation of the
very defectively designed and extremely expensive and wasteful family planning
programme. As if that was not enough, international agencies then come in with their
own prefabricated technocentric global agenda against some specified diseases
and managed to get the politician / bureaucrat to accord these unsuitable programmes
priority over the basic health activities .. .. and finally this has been further compounded
by severe cuts in budgetary allocation for health and social services; increased
. inefficiency in the use of whatever is allocated and gross inadequacies in finding more
cost effective programmes for social interventions to break the vicious cycle of poverty
and ill health ...."
- D. Banerji, India.
<>
Dr Zafrullah Chowdhury the second keynote speaker, characterised the period from
1970’s to 1990’s as one from “Hope to Hopelessness”. The 70’s was full of hopes. In
Bangladesh the War had ended. Independence was obtained, the struggle was over. This
was also the decade of Alma Ata. By the 1990’s the economic situation in the world had
changed. Even developed countries were witnessing significant changes in the field of
health care with cost of care spiraling and market forces becoming preponderant. In the
70’s scholars talked about ‘self sufficiency’; now in the 90’s they talk about
‘sustainability’.
He summarised the major components of the Health For All 2000 policy : education on
common health problems, promoting food supply and nutrition, adequate safe drinking
water and sanitation, MCH including family planning, immunisation against major
infectious diseases, etc. But over a period of time, with increasing drive for privatisation,
health care for the poor is being delivered at very high costs. Despite the World Bank’s
role in putting health top on the agenda, investment in health in most developing countries
15
is not adequate, if anything it has shrunk. He concluded his keynote speech by saying that
“we need to work together”, and have a sense of ownership, if we want to bring about
any significant changes at all in the health of the people.
This session was followed by brief presentations by Panel Members. They were: Mathura
Shrestha (Nepal), Myrtle Perera (Sri Lanka), Yousuf Memon (Pakistan), Abul Barkat
(Bangladesh) and John Martin (WHO, Geneva).
1.
Mathura Shrestha : spoke on the Peoples Perspective of the Poverty and Development
Paradigm
>* “We live in a world of un-equals. People are divided at various levels. Poverty and illhealth are the most painful remainders of unfinished tasks of this century. Poverty is
an artificial state created by human beings. We must find ways to come out of this
shameful existence.”
He stated that all over the world, where there is more egalitarianism, better health has
prevailed. South Asia has the highest concentration of poor people. In Nepal for
example only 10% of the people have access to public heath care facilities and not
more than 10% have access to sanitation facilities.
He argued for a change in the definition of the concept of development. The new
concept should emphasise “equity and social justice, and life in harmony”. We need
good governance which includes: distributive justice, participatory governance,
transparency, and accountability, among other things.
Poverty and Health of Indigenous People
Case Study: Nepal
Between 50 to 60 years ago, one could see quite a lot of 'Kusundas', in Tanahu - a
district in Western Nepal (Dr. Shrestha's home district). They belonged to one of the
most deprived ethnic groups. Many called them bush-people or forest-people. As a
child, one of us had the impression then that they were 'short and stout' people of
forest. They lived in closely social clusters and they were peace loving, shunning
violence, and strictly vegetarian. Every body exploited because of their unusual
tolerance and hard life. They, specially the children, were gifted singers and
musicians producing enchanting tunes from leaves, murchungas (Nepalese ethno
musical instruments), bamboo reeds (kind of flutes), Mauris (miniature bagpipe like
instrument with three bamboo reeds attached in a hardened wall of Bel fruit), wooden
logs, sarangis (stringed violin like instruments), and madals (drums). They subsisted
heavily in forest products. Occasionally, they practiced 'slash and burn' agriculture.
None possessed land. They were known to produce beautiful wooden and stone
utensils with which they occasionally bartered with the food grains of 'civilized'
people in villages. Now, one can see not a single Kusunda in Tanahu or nearby
districts. They became extinct from the area because of deprivation, exploitation,
poverty, rapid deforestation, landlessness, and exchange entitlement that was a gross
imbalance. Now some remnant clusters of Kusundas are living in a remote and
deprived areas of Kamali zone in Mid - western Nepal. There too, their population
dwindling and not growing.
Mathura Shrestha - Nepal
16
Ms. Myrtle Perera (from Sri Lanka) spoke about challenges in addressing equity issues in
Sri Lanka:
’-*■ The gross picture that is often portrayed in international literature on the state of
health in Sri Lanka conceals much inequity that prevails within populations.
s-> Her own research shows that there is inequity in outcome, utilisation and in capability
of people. In Sri Lanka, even IMR varies vastly across districts, in fact some districts
in the recent past have shown an increase in IMR. Also, she noted that in some
districts, the proportion of children with low birth weight has been increasing.
What is even more worrying, she observed, is the increasing trend in youth violence,
mental illness, occupational diseases, and pesticide poisoning.
In almost all districts, incidence of ischaemic disease is on the rise, but specialists are
concentrated in northern districts.
>♦ She argued that the present health care system in Sri Lanka is highly ill-equipped and
ill-prepared. Most policy makers seem to think that privatisation is the answer to the
problems being faced. Sri Lanka had tradition of being concerned for equity, but this
is no longer seen (at least explicitly) in the recent past. Serious inequities in the state
of health are being covered up in aggregate data.
3. Prof. Abul Barkat spoke on “Crisis of governance in public health in Bangladesh”.
His main thesis was that there is a crisis in governance of public health in Bangladesh. He
considered HUMANE GOVERNANCE as having three specific dimensions: Economic,
political and civic. Among the many crises that plague the system, he pointed out the
following as the most worrisome:
*-* Absence of well-organised structure of public health system - this refers to lack of
co-ordination, lack of responsibility to safeguard public health
Allocative imbalance across various sectors in the economy - this refers to increase in
military spending, upward trend in tertiary care, etc.
*-» Gaps between targets and achievements - this includes over targeting, ineffective use
and under utilisation of resource
»* Conflict between stake holders within health sector
Lack of public accountability - this includes, non-conducive environment for the
poor, people not being aware of their rights, feudal and bureaucratic involvement of
health professionals, huge wastage, lack of appropriate reward and punishment
system, large scale corruption, etc.
»-* Crisis in tertiary health care system, which is being highly mismanaged, misused, and
misgoverned.
Misuse of public health sector by private health sector. .
’-*■ Crisis in quality of services provided by both private and public health sector - there
is frequent complaint of ill-treatment of patients by health professionals, and
enormous increase in induced demand; and
There is increasing dependence on foreign aid - the crucial question is: who decides
in setting priorities and how are allocations made?
He appealed for a complete transformation from poor to humane governance.
diagram)
17
(See
Transformation from 'Poor Governance' to 'Humane Governance' of Public Health System in Bangladesh
Vicious cycle
Poor
Governance
1. Absence of public health system
2. Lack of people-oriented public
health policy
3. inadequate and inappropriate
public sector investment
4. Inefficiency in all sub-systems of
management
(planning,
organizing, staffing, coordinating,
leading, controlling)
5. Inefficiency in all sub-systems of
service delivery (logistics and
supplies, training, MIS, IEC, etc.)
6. Lack
of
inter-sectoral
coordination
7. Poor quality of care and services
8. Inadequate
community
participation
Virtuous cycle
1.
2.
3.
4.
5.
6.
7.
8.
Institutionalization of a public health
system
Development
of people-oriented
public health policy
Adequate and appropriate public
sector investment
Ensure
accountability
and
transparency of all sub-systems of
management
Ensure
accountability
and
transparency of all sub-systems of
service delivery
Institute
strong
inter-sectoral
coordination
Put highest priority on quality of care
and services
Ensure community involvement at all
stages (planning, implementation, and
monitoring)
Humane
Good)
Governance
18
4.
Dr. YousufMenton spoke on “Poverty and Health” from his experience in Pakistan.
Dr. Yousuf Memon of the Aga Khan University spoke about his experiences with Social
Development Initiatives in Pakistan and highlighted some key learning experience from
the involvement of his University in social development activities including Family Health
Project, Urban Health Project and School Nutrition Project.
The process of empowerment in communities is a stepping stone towards sustainable
primary health care and social development.
Community participation is of great value in improving the health of vulnerable groups
and determine greatly the sustainability of the programmes.
»-*• Continuous improvement in health interventions of a development nature like Safe
Water Supply, Sanitation and income generation were crucial.
»-* Increasing female para medical staff and creating greater linkages with community
health workers greatly increase access to services.
Access to services by the poor and marginalised is also increased by strengthening
referral systems and improving drug supplies and diagnostic facilities.
5. Dr. John Martin (WHO, Geneva) spoke about WHO’s perspectives on poverty and
health:
»-» He urged that we should be clear what we want and how we would like to achieve it.
He emphasised that we must first achieve international consensus in protecting the
poor. This requires putting the money where it matters.
*-» There is urgent need for designing alternative financing schemes for increasing access
to poor people. And there is need for a strong leadership and capacity to take the poor
forward through the hardship that they are facing.
Following the brief presentations by the discussants, Dr Devaki Jain, the Chairperson of the
symposium, made a few concluding remarks: “The major challenge seems to be" she said,
“how to bring the various knowledge together and how to galvanise the various forces in
giving voice to the voiceless”. She urged for more meaningful and effective reforms in
governance, which need a groundswell!!
The Marginalised in the Present Scenario
<>
Over a billion people are deprived of basic consumption needs.
■O
Three-fifths of the developing countries' people are deprived of basic sanitation.
<>
Almost a third of them have no access to clean water.
<>
A quarter exists with no adequate housing.
<>
A fifth live with no access to modem health services.
<>
A fifth of children do not attend school to grade 5.
O
A fifth of them do not have enough dietary energy or protein.
<
Two billion people are anaemic world wide, which includes around 55 million in
the industrialised countries
- Prem John, ACHAN
19
'
6. HEALTH AND POVERTY : EXPLORING THE LINKAGES AND
EVOLVING A FRAMEWORK FOR DIALOGUE
A pre-dialogue questionnaire and pre-dialogue brainstorming began a process of identifying a
framework to discuss the Poverty and ill health linkages and identify specific concerns and
context for action. After the symposium the first round of group discussions also explored the
links between poverty and ill health in six different contexts and some issues and concerns for
dialogue were identified.
FRAMEWORK FOR UNDERSTANDING
6.1
Socio-economic Deprivation and ill health
® Inadequate understanding of the dynamics of Poverty
® Exploitation and marginalisation of the poor by current economic policies including SAP
® Lack of educational / Social opportunities for women including girl child and gender
■ disparities
® Lack of commitment of policy makers for equitable development and distribution.
® Powerlessness of people.
® Increased hunger and malnutrition.
® Increasing education disadvantage and disparity
® Class, caste and gender disparities increasing vulnerability to ill health.
® Lack of access to minimum needs and other basic determinants of health like housing,
food, water, sanitation, income and land, can marginalise people and make them more
vulnerable to disease.
6.2
III health leading to Poverty
® Ill health causes decreased human capacities.
® Lack of access to health, nutrition and awareness building proceses keeps up the cycle of
ill health.
® Lack of relevant research focussing on determination of ill health.
® Malgovemance of public health increasing.
® Universal access to health care as a right not promoted adequately.
® Inappropriate and costly technology that is misused or overused can lead to further ill
health by reduced access or increasing cost of care.
® Alcoholism and other addictions produced a drain on income and productivity and lead to
a large number of diseases and social deprivation.
® Some occupational diseases lead to further marginalisation
® Unnecessary or excessive expenditure in funerals and other rituals / ceremonies following
death can affect health of other members of the family.
6.3
Feminisation of Poverty
Women form a major percentage of the proportion of the poor and marginalised in the world
and hence the term feminization ofpoverty. Various elements of growth and development
including newer economic policies are further worsening the condition of women - leading
to pauperization of women.
20
Some aspects of this feminization and pauperization in the region where particularly
significant
® The discrimination against women in the region was virulent expressed as a deeply
embedded son preference leading to female infanticide and foeticide.
® Sex ratios, IMR, MMR and discrimination in nutrition were all indicative of low status.
® Acute poverty of the region coupled with low status of women was responsible for some
phenomena like sale of children into the flesh trade; general trafficking in women;
increase in rape and incest; receding employment opportunities in a globalising,
liberalising world.
® Lack of health services is also leading to excessive of ill health - anemiajdepression;
increased abortion, mental stress, suicides rates etc.
® Women's poverty indicates both the specially deprived and discriminated condition of
women as well as the impact of economic policies that encroach into the spaces that
have provided families with wherewithal for life namely livelihoods, water, fuel, child
care are being encroached upon. This broad framework needs response at multiple
levels.
6.4
Globalisation and health
® Widening economic gaps between rich and poor; between and within communities.
® Impact of globalisation and privatization on human development and health.
® Discriminatory aspects of world trade organisation and other evolving International
regulatory instruments.
® Unequal distribution and utilization of global resources.
® Increasing debt burden of heavily indebted poor countries.
® Subservience of WHO to dictates of G-7 through donor control over health programmes
and an obvious shift in perspectives of WHO inhouse personnel and consultants.
6.5 Poverty, Ecology and Health
® Concept of ecological poverty - i.e., heavy degradation of the environmental resource
base of people whose local economy depends on these resources.
® Ecological changes and environmental degradation including industrial pollution,
chemicals in agriculture, unsanitary surroundings in urban slums and rural areas.
® Need to empower communities to manage and increase their own resource bases to
create greater ecological and economic wealth.
6.6
Disaster, Poverty and Health
® The effects of War, Conflicts on health.
® The effects of natural disasters like earthquakes, droughts, floods on health.
® The worsening of poverty conditions in disaster situation.
® The effects on women, children and other marginal groups.
® How can the public health system be geared up for immediate response and to tackle the
problems produced by disasters?
® What collaborative efforts can be made to prevent and counter the adverse effects of
natural and man-made disasters?
21
j
FRAMEWORK FOR ACTION
Some overall perspectives on Action initiatives also evolved in the pre-dialogue process and the
group.
6.7
Key initiatives to tackle issue ofpoverty and ill health \regionally\
0 Increasing awareness of the linkages between poverty and ill health and greater evidence
collation through participatory research;
0 Vigorously pursuing poverty eradication programmes and policies;
0 Providing comprehensive health care with emphasis on women and children's health at
subsidised cost;
0 Creating mechanisms to assure universal access to health care irrespective of capacity to
pay;
0 Ensuring good governance of public health;
O Increasing integrated socio-economic planning particularly through district level
decentralilsation;
O Increasing investment in health and public health services;
O Analysis of health impact of various loans and investments in all sectors including health
impact of developmental projects;
0 Implementation of more pro-poor health policies;
0 Giving greater emphasis on grassroots democracy and empowerment of the marginalised.
© Greater social action towards gender justice and equality;
© Resolution of conflicts and cessation of war.
6.8
Key initiatives ^loballf to tackle the issue ofpoverty and ill health
0 Assign top priority to poverty eradication policies and implement ways and means of
minimising acute vulnerability of the poor;
0 Sustain policy focus and funding on poor regions and poor people;
0 Interorganisational dialogue between WHO/UN agencies /WB/NGOs to democratise
global decision making and soul searching on reasons of policy failures and distortions;
0 Moratorium on debt servicing;
O Promoting just trade practices;
0 Promoting pro-equity and sustainable development models through greater south-south
and south-north dialogue;
O Tackling inequity in research and development in world and increasing access to
information;
O' Tackling powerlessness by greater gender sensitive social development, micro financing
and local decentralised decision making abilities;
0 Strengthening equity initiatives of WHO and other Health and Social development
organisations;
0 International controls of arms industry and also greater commitment of developed
countries to reduce / rationalise their consumption patterns.
22
7. GLOBAL, REGIONAL AND NATIONAL CONCERNS
IMPACTING ON POVERTY AND HEALTH
In this session many participants identified and discussed concerns that were significant at
global, regional and national levels.
7.1
Globalisation and health .
©
Deleterious effect on Health and Nutrition especially women and children.
®
Erosion of local culture by an importation of alien values
®
Increasing social violence and militarisation.
0
Increasing of privatization has led to commodification of social services like health
and education.
0
Deregulation has led to uncontrolled prices of commodities including price of essential
drugs.
O
Liberalisation of trade has brought about inappropriate consumption patterns
O
Shift of capital from productive purposes to the speculative markets.
©
Increasing weakening of the state, reduction in the sanctity of borders,
disempowerment of the south.
0
Lack of control of the state on the increasingly privatising health industry.
0
Poor have to pay much higher proportions of their meagre incomes for survival with
increase in vulnerability and indebtedness.
"All this is having serious consequences for the health of the poor and marginalised who
seem to have become victims under the new dispensation. There is need for NCOs to
promote legislative action and to bring people back into the central role in public
health, so that indigenous capacity can be rebuilt and the people's movement against
globalisation can strengthen the countries self reliance."
7.2
WTO and Health Agenda
The effects of the new WTO on health
© The commodification of agriculture and the drive to encourage commercial crops has
driven the rich and powerful fanners to usurping common properly resources that were f
essential to maintain the lives of the marginalised and poor.
© The increasing control of seeds by multi nationals is increasing a culture of dependency
in agriculture.
O Cost cutting drive and lack of protection from governments enforced by WTO are
making rural artisans disappear.
0 The new world trade order will not only increase the burden on women but may also
increase the number of poor and street children.
UJ I. ItWWI
_________________
"When we talk about the poor, we shall have to decide whether food was meant
for trade or for nutrition and freedom from hunger...."
23
7.3
Intellectual property rights and commodification of Health
®
Developing countries have also got in a rush to 'go private by any means' and this rush
and push of commercialisation has pushed the poorest people to the wall.
0
The New Patent laws do not recognise traditional knowledge and traditional systems
of ownership and the grossly unfair patenting of rNeem' and 'Turmeric' was
demonstrative of this fact - since both are age-old herbal medicine remedies used by
indigenous people.
©
Traditional knowledge that has allowed the control of diseases in the hands of
common people is now being denied under the IPH rhetoric and is threatening the self
reliance of people and their access to home remedies.
"We have entered a phase of 'paradigm paralysis' and 'aspect blindness' that is
preventing us from thinking about the poor and marginalised. The IPR regime has
been the ultimate instrument that had been used to colonise the minds of the South"
- Mathura Shrestha, Nepal
7.4
Privatization and Health
0
Health care system development in India has seen the unbridled expansion of the
private health sector thanks to state subsidies in the form of medical education, soft
loans to set up medical practice etc. The private health sectors mainstay is curative
care and is growing over the years at a rapid pace largely due to a lack of interest of
the state sector in non-hospital medical care services especially in rural areas. Private
sector accounts for over 70% of primary care treatment sought and over 40% of all
hospital care. This is not a very healthy sign for a country where over three fourths of
the population lives at or below subsistence levels. The trend is similar in most of
South Asia.
0
Private medical practitioners operate under conditions of complete absence of controls,
monitoring or regulation by either the government or professional bodies whereas the
public health sector is inadequately equipped to meet the health care demands of the
poor, the private sector meets them without consideration of quality, rationality and
social concern.
0
Private sector in health care must be recognised and permitted but would need good
regulation. State must control and regulate it. Eg., lack of regulation has led to a
condition that 'supplier induced demand has caused a place like Mumbai to have about
55 CT Scan Centres but a place like London has about three'.
0
This regulation would include licensing; setting up standards of practice and care;
strong restrictions and disincentives in overserved areas and incentives to set up
centres for underserved areas; norms for access and availability and disparities and
health of the poor. A small established section of the medical profession would
oppose any organised system of health care because it would threaten their position in
the health care market. But regulating provider behaviour is necessary.
"Health is one of the goods of life to which man has a right, wherever this concept
prevails the logical sequence is to make all measures for protection and restoration of
health to all, free of charge; medicine like education is then no longer a trade - it
becomes a public function of the State"
- Henry Sigerist
24
7.5
Breakdown of Public Health System
0
Public Health in many parts of South Asia has no money, poor quality and those in it
had very poor motivation.
0 The health sector is very poorly integrated with the other development sectors.
0 Centralised control over the public health system also means that communities have no
control over health service or its management.
O There is not enough priority for Primary Health Care in the overall plans.
0 There is no effective mechanism to converge public / private and voluntary health
sector.
All these factors, further worsened by the newer economic policies have led to a breakdown
of the public health system at all levels. The poor are the most affected by this breakdown.
7.6 Neglect of Traditional Systems of Healing
0
0
0
Traditional systems of healing and healers have been greatly neglected even though
these have been used for centuries by all people and especially poor and marginalised
who have regularly accessed locally available herbal medicines and folk health
traditions.
The neglect in the past has now been compounded by International trade laws
including IPR and there is a great possibility of a loss of these traditions, knowledge
and skills if suitable action is not taken by all those who are concerned about the health
of the poor.
The need to study, evaluate, promote and promote traditional knowledge systems in
health must be done in such a way that the access of the poor to their own herbal
medicines is protected and not jeopardised by commercialisation of these resources by
multinationals and others.
MMcmga—WMW—— ----- - —.----------------- FW—
"We have come to the shameful point of time when the poor are not needed anymore,
because machinery and technology can replace them. Earlier for better or for worse,
at least there was a need for them"
7,7
Conflict, Poverty and Health
0
One of the major effects of war and civil disturbances is to bring about a deterioration
of the health status of the people. War leads to poverty and ill health and these in turn
contribute to each other making living miserable.
®
War affects the economy of the countries involved by affecting socio-economic
conditions - like loss of employment; damage to industries; and migration of skilled
persons and the wealthy. It also greatly affects the education and health services.
♦
♦
War has disrupted all sections of the economy in the Northern provinces - agriculture, fisheries, manufacturing and trade.
59.3% of families in Jaffna now depend on rarions
♦
♦
♦
♦
*
20% of agricultural land is inaccessible to civilians because of high security areas.
The educational system has been affected due to damage of schools, migration of teachers and frequent displacement of
people. Many Schools are used as refugee camps.
IMR and MMR has increased tremendously and peaks during the times of escalation of war.
Increase in anemic and low birth weight babies have increased.
Under three malnutrition has increased by five times.
♦
♦
An average of 10 persons are injured by landmines and unexploded devices every month. 25% of these are children.
55.8% of Malaria in Sri Lanka is in the North East Province which has 14% of the population.
♦
Psychological ill health is a major problem.
r;
The Ethnic War in Sri Lanka
I
- Sivarajah - Sri Lanka
’
25
3. POLICY ISSUES FOR EQUITY IN HEALTH AND POVERTY
REDUCTION
A wide range of policy issues emerged as significant to Poverty reduction and Equity in Health
challenge.
8.1
Strengthening Civil Societies
The two principal features of civil society are humane governance and social capital.
These have declined even in democratic countries like UK because of the gradual
decimation of democratic accountability and forms of democracy by the focus on market
forces. This has resulted in social exclusion reaching very high proportions; without
democratic safeguards nothing worthwhile to improve well being of people especially the
poor can be done. The current labour government is beginning to redemocratize and roll
back initiatives of the past governments.
8.2
Promoting Intersectoral Action
There is need for synergistic action between health and environment and development
initiatives. Action initiatives need to be at all levels - local, national, international and we
need to identify expertise at various levels and tap their resources.
Intersectoral action must include developing an evidence base; conducting case studies of
successes and failures; developing a common agenda; involving key players; identifying
win win situations; overcoming barriers; creating public demand, developing south-north
link; reinvigorating the public health system; and increasing the involvement of poor in all
levels of action.
8.3
Tackling powerlessness through empowerment
Understanding cultural issues enables us to know what people think when they are sick
and what action they would prefer to take during the sickness episode, and thus what role
PHC has to play in the healing process. This listening and learning from people is an
important skill of all those who wish to work with or reach the poor and marginalised with
well developed listening / learning skills strategies that empower the people and move
them beyond their state of powerlessness can be evolved.
The Cultural Context of PHC
Case Study : Marabo, Congo
A health and poverty survey was conducted by the communities with technical support from
students in a village in Congo.
The village was described as marginalised, 'uncooperative', demotivated, apathetic,
powerless, under 5 year malnutrition was 53%; and immunization coverage was + 20%.
15 months later the survey had stimulated a process which led to the following :
i
Fields and gardens had nutritious crops; School attendance increased; Protected
water source (escaped cholera epidemic); Construction and use of health centre;
Community discipline protected against rape; Malnutrition <10%; Immunization >
80%; Antenatal clinic > 90%; Evidence of confidence and shared decision making.
A Survey to identify poverty and ill health can be useful if information is gathered and used
by communities in their overall development plans. It may be useful to measure impact of
action. Its not very useful if only for targeting individuals and families.
26
Politics of Health Policy implementation
8.4
TB is a curable disease, yet thousands of people die of it every year. We have policy
statements but the focus on implementation is very inadequate. The political context of
health policy implementation must be adequately understood if this implementation gaps
have to be tackled effectively.
Who decides policy and who controls it? What are the stakes and conflicts of
interest?
ii. Why are donors insisting on DOTS as the only method even though there is resistance
from eminent scientists and policy makers? Why cannot flexible approaches be
allowed?
iii. Is DOTS shifting responsibility in the system to the poor and health workers at the
lowest level? Is it coercive?
iv. There is politics at delivery level as well with lots of negotiations taking place
between doctors, health workers and patients which allow for distortions in the plans.
v. There is enormous apathy at all levels?
©
i.
All these micro political elements have escaped the attention of policy researchers and
hence TB programmes are not effective on the ground.
impact of implementation gaps on patients, families and society
It is a reflection of the structure and priorities of our society that we spend millions
obtaining the latest medical technology, even in government institutions to diagnose
relatively untreatable conditions, while resource constraint arguments are put forward to
fund the treatment of killer diseases like TB which can be diagnosed relatively easily and
cured. When one considers the amounts spent for sports extravaganzas and defect of
borders, the disparities become more start and obscene. Somehow, the loss of half a
million lives is not considered a national security problem calling for the best and urgent
social defence. Some lives perhaps are more important than others.
- Thelma Narayan, India
Identifying research priorities
8.5
Research priorities in the area of understanding poverty and health must arise out of the
researchers local interaction with social realities and the local situation. Often health
research has to look carefully beyond the health sector at the deeper determinants of health
(non health sectors). Each country has to decide its own research agenda and not allow
international funding partners or the market economy in research to evolve priorities.
8.6
Role of Private Practitioners
The private practitioners' is often the first line of call before the poor reach government
. services or NGO services. They are often ignored by policy planners and decision makers.
The private practitioners need to be oriented and encouraged to focus on preventive
measures at all levels. They need to have skills to handle epidemic situations. They need
to be sensitized to key issues of women's health, occupational health, mental health and
environmental health. They need CME's; back-up support for referral cases; and attempts
at formal or informal standardization / accreditation.
The people, must also be empowered to lessen their dependence on them and at the same
time use their services judiciously.
27
S. 7 Health Humanpower development
This is a very neglected issue but an important one. One of the most crucial challenges of
equity and access of health care for poor and marginalised is the availability of
pro-poor, equity sensitive, health humanpower - doctors, nurses and other health
workers to run the increasing number of primary health care centres that are required
to reach the poor, both in urban and rural areas. How is this possible in the present
scenario marked by growing, uncontrolled, privatization of health humanpower education
and training institutions; and declining professional standards at all levels? There is
therefore urgent need to
<estimate humanpower needs;
«• promote generalists rather than specialists;
<review and revise the curriculum for all cadres to make it more community oriented;
strengthen all curricula on behavioural sciences, ethics and values, ecology,
management and health economics;
o provide continuing education at all levels;
■o promote alternative methods of training and pedagogy;
«•
enhance competence based learning strategies.
This is an urgent task which should not be further delayed.
8.8
Basic Minimum Needs approach
Any process of measuring inequalities in health invariably results in the discovery that
absence of access to basic determinants of health are an important component of the
inequalities. Hence all health interventions must focus on basic determinants like water,
sanitation, housing, a living wage and so on. A basic minimum needs programme must
therefore be considered. This BMN initiative would begin with people, involve all
sections and ultimately emphasise better quality of life.
"The concept of basic minimum needs should include adequate access or entitlement to :
Food (calorie intake); clothing, housing, education, health, security including social
security, productive employment with income, progressive development (physical, mental,
intellectual and social), participation in social and political affairs outside ones home, active
communication (for social relations); recreation and entertainment, and human rights"
,
28
- Mathura Shrestha - Nepal
9. HEALTH AND POVERTY ERADICATION - THE ROLE OF
INTERNATIONAL AGENCIES : PERSPECTIVES AND
CONCERNS
During this session representatives from the World Bank and WHO (at various levels) presented
their perspectives on Health and Poverty eradication.
9.1
World Bank and Health (Richard Skolnik)
® The bank was concerned about the increase in poor people; increasing population; an
ageing population; an urbanising population; malnutrition.
0 It had identified the high fertility and population growth, malnutrition, high infant and
under five mortality rates, maternal mortality, women's health, communicable diseases;
especially the new ones as critical issues.
0 It was also concerned at some of the new and emerging diseases, environmental health
issues, post-djsaster situations.
0 The bank had in its experience noted that health system initiatives of government often
had corruption; weak management structures; inefficiency / lack of quality, misallocation
of resources, higher costs, lack of resources or concern for the poor.
O The bank would definitely like to support community based primary health care but
there were always ongoing debates on the approaches and addressing poverty, health,
nutrition and equity was one of them. Other approaches included
•
•
•
•
♦
structural adjustment;
sector wide approaches;
redefining public health priorities;
defining international public goods;
role of public sector and private-public partnership. There was also urgent need to
monitor and evaluate the outcome of different strategies.
O The road to the future was to work on broader framework that should focus on outcomes
and quality and would include some or all of the following :
♦
•
♦
♦
♦
health is an absolute right;
ensure governments are obliged to respect the rights dimension;
shift money to public health;
improve governance;
empower people and enhance transparency.
I
po~rc^^i
B "In South Asia, poor people should be seen as a National disaster"
- Richard Skolnik, World Bank
|
9.2
WHO and Health (John Martin, Robert Kim Farley, B.S. Laniba)
0 WHO\ may not have had a credible policy on poverty eradication in the past but the 1998
document focuses on health for all; on poverty; on equity; and on protecting the health
status of the poor for whom health is the most precious asset.
29
® WHO's new policy was focussing on
V.
•
♦
•
•
•
multisectoral action;
on socio-economic policies;
bn health systems that were financially and procedurally fair;
bn reducing risk factors and determinants of ill health;
and bn reducing the burden of excess mortality and morbidity.
® WHO was trying to make a difference in an already globalising world, and the dialogue
with the trade world starts at SEATTLE WTO review meeting.
® WHO was under pressure from Northern academics to dialogue with the pharmaceutical
industry, and other industries as well. There was a virtual lack of southern perspective in
WHO and there was urgent need for voices from the South to reach there as the
environment at the moment for listening is rather good.
i,cr , r/
'
© WHO SEARO was trying to sensitise the Ministry of Health of various countries on
implications of various current events, eg., globalisation; Intellectual Property Rights
issue; collapse of South East Asian economies and the effect on the health of the country.
In India it was looking at Health legislation and trying to find ways and means to
strengthen it in the context of issues of pollution and waste management. The challenge
was to see how social capital could be increased and how health could be integrated into
social policies.
"Health is the most precious asset of the poor and we need to protect it"
- John Martin, WHO, Geneva
® The challenges before us are
i.
Health professionals and other committed to Equity and poverty issues must dialogue
proactively with other action
ii. Epidemiological evidence must drive WHO programmes.
In the discussion that followed participants raised some important issues about WHO and
WB perspectives and programmes.
* There was concern that the cost per unit developmental programmes in different
countries was very variable with poorer countries like Nepal being higher than
neighbouring India.
* Why did WHO dilute its commitment to Primary Health Care in recent years and
promote more selective strategies/;
» How were World Bank and WHO collaborating when the former believed in the
policies of health to only those who could afford to pay while the latter believed in
Health for All. ?
AxJW-Tm. re
9.3
■ Some-implicati&ns-of-International Collaboration: A Caution
Earlier in a session preceding this CHC presented a critique of World Bank activities in the
Health Sector in India based on the Banks own reports including a recent case study by its
30
y
?juMj
Operations Evaluation Department of HNP programmes in India. The concerns about the
projects included :
(
1.
Public Health devalued
Disturbingly lack of public health competence including lack of public health orientation
and competence among the policy / project formulation
* Confusion between socio epidemiology and techno managerialism
♦ Ignoring of basic determinants of health
• Absence of focus on poor indigent and marginalised
» Regional diversities and disparities not adequately addressed
2. Primary Health Care sidelined
project partnerships totally uninformed about local formulations and expert
committee recommendations
focus on.selective strategies that make community needs, aspirations and capacities
of communities subservant to needs of technology or the exigencies of topdown
management systems
ignores Panchayatraj and focuses on creating Registered Societies
focus on secondary hospitals rather than primary health care; first referral units
rather than primary health centres.
»
*
»
•
3. Unconstitutional partnerships
• seeking to influence health policy even though contributing to small part of
country's health budget
» conditionalities in project formulations that often overrule local expertise and
formulations
• funding muscle during periods of economic vulnerability
• is World Bank willing to bear the costs of failures or distortions due to poor or
inadequate programme planning that ultimately affects the poor the most?
• accountability and transparency of projects that are often top down, externally
inspired affecting local capacity development and distortions of existing health
system.
4.
Ethical issues involved
Promotion of private sector in the absence of evidence of its capacities for public
health or primary health care.
Ethics of continuing with projects when the bank is aware of flaws, distortions of
the contract guidelines.
Ethics of expanding 'quantity1 over 'quality' or 'infrastructure' at the cost of services
focussing on the poor.
♦
*
»
5. Management issues
Some problems encountered are
*
*
»
*
»
Inadequate focus on mechanisms for accountability and transparency
Absence of credible external evaluation
Focus on 'user fees' rather than diverse fund enhancing options
Inadequate attention to health humanpower development
Inadequate focus on long term ownership and sustainability
31
6. Political economy ignored
°
«
Project planning focuses inadequate attention on the political, social and
institutional dimensions of problem analysis including financial situation in the
country’ and globally; reduction or stagnation of budgets; rise in prices of drugs and
diagnostics; impact of liberalisation, privatization and globalisation on public health
and access of poor to medical care; the potential impact of WTO and changing
patent laws; increasing corruption etc.
Finally there is need for building inhouse capacities in Ministries / Directorates of
Health and Family Welfare in Public Health Policy and programme planning
without too much reliance on adhoc freelancing consultancies and studies that
sideline such capacity building.
Suggestions forfurther dialogue and action
9.4
A small group discussion held on the theme of International Donor Agencies later in the
programme evolved the following perspectives and suggested some action initiatives :
1. International Donor Agencies including bilateral and multi lateral institutions,
intergovernmental agencies; non governmental agencies including foundations,
philanthropies, voluntary organisations and private sector initiatives. They have different
perspectives and support different types of projects. Newer players are international
banks, European Union and others.
2. They often have similar programmes and agendas because study promoted by one agency
is shared through agency networks; or network of donors support specifically identified
thrusts/priority programmes and projects.
3. Four concerns were identified as priority concerns in the context of the 'poverty and
health' theme.
a.
'User fees' concept now promoted by many agencies may affect access to health care
of the poor and marginalised.
b.
'Privatization' thrust without adequate evidence of capacity or orientation of private
sector to primary health care or public health priorities may lead to distortions that
affect long term goals and sustainability.
c.
'Consultancies' system that focus on freelancers and adhoc arrangements and
external agencies mediating through a bidding process may prevent inhouse capacity
building of health ministries and directorates.
d.
Promoting large development projects that promote import/export of labour and
increased migration / displacement will enhance inequities.
4. A concerted effort must be made at all levels to dialogue with international donors and
enhance the equity agenda in their work and mobilize their support towards this end.
.
i.
Bringing back Equity on the agenda of international donors
ii.
Focussing on debt burden / debt servicing related issues
iii. In all programmes there should be an Equity focus i.e., benefits must go to the
poorest of the poor.
iv. Policies plans must be initiated or made by recipient countries with planning and
formulation carried out by governmental representatives; NGO's; peoples
organisation representatives and national level experts who are independent.
v.
Projects and plans should be transparent
32
vi. Issues in implementation should be considered or' the policies formulated are
operationalised.
vii. Local expertise must always be tapped and built up
viii. Need for good data and information that must be also available for public debate.
5. A similar orientation/dialogue must also be made with national policy makers, decision
makers - both technocrats and bureaucrats and consultants.
6. Finally when we make any project I programme decisions, we must all 'think of the poor'.
Would our programme make them poorer or help them to rise beyond their poverty?
The Unfinished Agenda
"There is a need to focus on a large unfinished agenda for the third
world poor, especially women and children. They live in country
caught up in debt, financial crisis imposed upon them by
international capital markets, down sizing of public sector health
care, not including endemic conditions of war, agricultural failure
etc. Such a steady focus on nutrition prevention and low cost
curative services with quality needs sustained public investment in
health recognised to be the state responsibility for social
development. As against this, the concept of sustainable health
development, based on cost effective intervention in diseases,
selected for value for money, would leave the overall health
situations in these countries in total disarray".
- South Asian Group (VHAI)
10. ACTION FOR CHANGE - SOME INITIATIVES
EMERGING STRATEGIES IN SOUTH ASIA
AND
Many participants presented case studies of Action initiatives from their countries where
approaches to tackle the challenges of poverty and ill health was being evolved. Six case
studies which had been circulated are outlined here. (There were many others like the work of
Gonoshasthya Kendra in Bangladesh, and smaller case studies' which were shared by.
participants as part of their reflection on other issues. These are being included in the larger
companion publication).
10.1
Poverty and Health : Experiences from SEWA (Self Employed Womens Association),
Gujarat, India
Background : 94% of women workers in India are working in the unorganised sector that
prevents them from accessing legal and social security and from getting the benefits of
the organised sector like health and finance. An average woman spends Rs 800 (SI8) per
month on illnesses for herself or her family leading to a cycle of deteriorating health and
increasing poverty. SEWA has tried to change these conditions since 1972 in Ahmedabad
and elsewhere in Gujarat.
Strategy : SEWA is a confluence of the trade union movement, women's movement and
the cooperative movements. It believes in organising women to achieve their goals of full
employment and self- reliance and uses the strategy of struggle and development to
strengthen the bargaining power of women and to offer them alternatives.
Methods
•
women's cooperatives based on employment that bargain for better wages and social
security.
•
•
•
women's banking run by members of SEWA that provides
for micro-credit for
enhancing their employment opportunities of women’s credit groups.
employment generation activities involving women like dairy cooperatives, bidi
rolling, tailoring, embroidery, designing, etc.
health activities like health education, provision of primary health care by community
health workers, mobile clinics, studies on occupational health, low-cost alternative
therapies, TB treatment, and an integrated medical insurance scheme.
Results : SEWA’s experience with over 210,000 workers in six states shows that poor
women when organised and allowed to run, manage and own their organisations, have a
better health status and quality of life by virtue of identifying and paying for services that
improve their financial and health status.
10.2
Talking Poverty and Powerlessness for Community Health - Sarvodaya (Awakening of
Everyone) Shramadana (Voluntary Labour) Movement, Srilanka
system well-run by the government, a
large section of Sri Lankan society is devoid of comprehensive health services because of
social, economic and geographical inequity. Sarvodaya Shramdana Movement (SSM) in
the past thirty five years has been able to reach an exceptionally large proportion of Sri
Lanka’s underprivileged communities through an integrated approach to community
health.
Background : Despite a good curative medical
SSM has helped to set up thousands of legally independent rural and urban
communities that acquire a better understanding of the forces and circumstances that
inhibit their development and thus gain confidence and the skills to act effectively on
Strategy :
34
their own behalf. While organising programmes to meet the immediate health and
nutrition needs of the community, Sarvodaya lays the foundation to address the deeper
causes of ill-health, namely poverty and powerlessness.
Methods and techniques : Keeping the core principles of self reliance, community
participation and planned action, the communities are organised through five stages:
Stage One (Psychological Infrastructure building)
Request from village => visit of SSM worker => discussion with village elders => priority
identification => Introductory Shramdana' camp in which villagers/families/govemment
extension officers and villagers from other SSM villages participate to discuss local needs
and organise self-help activities.
Stage Two (Social Infrastructure building)
One or more community groups of farmers /mothers/youth, etc. formed => training of
such groups in leadership and skills for running community help programmes =>
establishment of children’s services centres/ day care centres/ health clinics/ village
libraries / community kitchen, etc.
Stage Three (building legal community based institutions)
Establishment of legally independent Sarvodaya Shramdana Society with hierarchy re
survey of ten basic human needs programme => priority listing => village development
plan => access to inputs for income and employment generation e.g., community
shops/farms/industry/contracts/saving and credit/cost-benefit analysis.
Stage Four (building self sufficiency)
Ideological and skill training => structural changes => costing /pricing/marketing skills all
leading to building self - sufficiency.
Stage Five ( supporting other communities)
Providing support to other communities by sharing experience and guidance, providing
capital, labour and raw material.
For building community capacity in tackling community needs, SSM takes the help of in
house specialised support units like Management Training Institute for leadership
training, Rural Enterprises Development Services for technical support for agriculture,
business and product development, Sarvodaya Rural Technical Services for technical and
financial support in the fields of water supply, sanitation, energy and transport, and the
Community Health and Environment Unit for technical support in community health.
Results : SSM is active in more than 8000 villages and has already facilitated the
formation of more than 2500 dynamic village level societies that are responding to the
growing challenges affecting the lives of community members in league with the
government.
10.3
Peoples Participation in the Maldives - South Asia Poverty Alleviation Programme,
Maldives
Objectives : Providing local communities with direct access to resources for financing
development projects while guiding and directing community based organisations and
NGOs in their formulation and execution.
35
Strategies
•
Participatory rural appraisal of communities for identification and prioritising needs.
♦
involving local community development organisations, NGOs and government in
training and capacity building for planning, implementation and evaluation of
development activities.
♦
gradual transfer of responsibilities to local community development organisations of
various islands and atolls.
Achievements
♦
community mobilisation in island development.
♦
harbour improvement to enhance economic development activities.
♦
safe drinking water by installing and improving tanks to reduce water-borne diseases
and better electrification.
♦
income generating activities like fish-salting, agriculture and preschool construction
and upgrading that are planned and managed by communities or community
development organisations.
10.4
♦
human resource development for training women in tailoring and agriculture.
•
savings and credit mobilisation in collaboration with banks.
People's Campaign for Decentralised Planning - Kerala Shasthra Sahitya Parishad,
Kerala, India
The health care crisis as it exists in Kerala is characterised
by low mortality but high morbidity, resurgence of infectious diseases, rising diseases of
affluence, overgrowth of the private health sector at the cost of the public health system,
rising health expenditure and marginalisation of the poor.
Kerala Health Care Crisis :
Goals : The people’s campaign aims to strengthen the local bodies for financial and
planning decentralisation, solve the development crisis by increasing production and
improving the quality of the services sector and initiating a new development culture
while specifically targeting all the crisis points identified above. The overall aim is to
provide good health at low cost and with social equity.
Strategy:
•
Decentralisation of health services as a basis of community involvement in health.
*
Structural changes in health systems like decentralisation of planning, management
and budgeting.
Activities : After decentralised planning, the panchayats (elected local bodies) carry out
the following health related activities:
* integrated disease control programmes ♦ specific disease detection camps * geriatric
care * school health programmes * rural cleaning campaign * nutrition programmes
♦ sanitation ♦ water supply * health survey * strengthening hospital infrastructure
Achievements : The Kerala health sector reform by involving the community in health has
been able to bring about:
♦
a thrust on preventive and promotive health
♦
innovative health programmes
36
*
a better working partnership between health workers and people
♦
reallocation and availability of health resources
The ninth five year plan has allocated 37.25. of the state budget to the local plans drafted
by the local municipal bodies and panchayats of different levels, thus recognising the
better utilisation of funds and implementation of programmes for better health.
10.5
Basic Minimum Needs Programme for Primary Health Care - The Nowshera Project,
North (Vest Frontier Province, Pakistan
Background : NWFP is a backward hilly province in the North West of Pakistan, known
for its socio-economic poverty and class inequities that influence its poor health
indicators like infant and child mortality indicators. Basic Minimum Needs
(BMN)identified by the people in the programme were:
* water, irrigation. * food, agriculture. ♦ livestock for income generation.
* environmental health. * education. * health.
Concept : Basic Minimum Needs concept is an integrated bottom-up socio-economic
development based on full community involvement and self-reliance through self
management and self-financing, supported through intersectoral collaboration and
partnership by the government line departments. It is a self-sustained people oriented
strategy.
The BMN programme run by the government of Pakistan involves
community preparation, selection of community representatives, community survey,
community based analysis, priority setting and project formulation by the community.
Methodology :
The three interdependent pillars of self-reliance on which the BMN approach is based are:
♦
community organisation for planning and management.
♦
training in appropriate technology and provision of information to community.
•
community financing through village revolving funds and village cooperatives.
Appropriate education, appropriate agriculture, appropriate health and appropriate
community development cannot be seen as watertight compartments and their integration
from conceptual to worker level has produced tangible results in the relevant
communities.
Results : In Nowshera (NWFP), the Infant mortality rate dropped from 117 to 61
per
thousand live births in two years. There was a 52%increase in boys enrollment and 65%
increase in girls enrollment in Nizampur (NWFP) in the same period. Prevalence of third
degree malnutrition dropped from 11% to 2 % as a result of the BMN programme in
Nizampur while the immunisation rates reached an unbelievable 96 to 99% in the pilot
areas from a dismal average of 25% in the same period. Loan recovery for income
generation activities ranged from 77 to 98%.
10.6
Decentralised Management of Community Based Primary Health Care t Towards a
Community Health Guarantee Scheme - Madhya Pradesh, India (An Action Proposal)
Background : Madhya Pradesh is India’s largest state and its per capita income is the
third lowest with 37% of population living below the poverty line. Its basic health
indicators like Infant and Child Mortality Rates are far above national averages and
diseases like TB, leprosy and water-borne diseases have a heavy toll on human lives.
Although government spending has increased over the years, people living in far-flung
areas and tribals have little or no access to the public health services.
37
Strategy :
♦ ■ Decentralised health action through comprehensive institutional reform.
♦
Involvement of elected Panchayati Raj Institutions (PRIs i.e.Elected village level
legislative and executive bodies) as partners in identifying health issues, health
workers and managing the state sponsored schemes.
•
Intersectoral and inter-donor coordination for harnessing and allocating resources for,
health service programmes.
Core Components-.
10.7
•
People’s health survey and health action (Lok Sampark Abhiyan).
♦
Panchayat* level health plans and guarantee by panchayats - with government
support - to deliver a package of basic health services like safe water supply,
sanitation, immunisation and child nutrition.
•
Community health activists as paid service providers that are selected by panchayats
and trained by the government to cater to the basic health needs. Also training of birth
attendants for skill upgradation. Linking up of these workers with the public health
system (Jana Swasthya Rakshak).
♦
Involvement of private health sector
♦
Strengthening of district level health units (including private sector) and district level
health services management in cooperation with other departments.
Poverty and Child Disability - Case Study: Bangladesh
A ten-point questionnaire was used in a door-to-door survey of 1000 families. All
children found to be potentially in need of disability services were invited to the Centre
for assessment, treatment and rehabilitation based on both the Centre and their homes.
The families were initially cautious and each one had to be persuaded by a social worker
to attend.
In the five years since this project began, many of the initial notions about the community
and the objectives have had to be modified. In particular the social development of
families and the community, and the general health services for mothers and siblings,
have been integrated into the project. Extra space has been allocated for the project in the
outpatient department of the hospital. A regular health care and disability service is now
operating, and parents attend on the recommendation of friends. The screening process is
no longer required as the community itself identifies the children requiring care.
Parents with disabled children in Bangladesh are becoming increasingly concerned about
their quality of life. A public health approach to the care of such children is necessary if
they are all to be reached. It is important to deal with the social factors that lead to
disability, such as poverty, social discrimination, and undemutrition. However, once a
child is identified as disabled he or she becomes a responsibility of the health sector.
Scarce resources should be used to adapt low-cost procedures based in the community
and the home which have proved beneficial. Tertiary care is also required but its cost
should be bome by local business people.
3S
11. SOME EXPERIENCES AND
PERSPECTIVES FROM
BEYOND THE SAARC REGION : South-South and SouthNorth dialogue
While the South Asian Dialogue on Poverty and Health focussed much of its discussion on the
situation and context in the South Asian region, the dialogue had participants from other parts
of the globe, and a session to leant from experiences from other areas and countries in a spirit of
South-South and South-North dialogue was held.
11.1
Health consequences of the uninsured in the U.S. (Whitney Addington, U.S.A.)'
The American College of Physicians is a professional association of over 600,000
physicians who are concerned that a growing number of people in the U.S. are
uninsured and this includes the poor, the blacks, the elderly and the marginalised. The
Association is now campaigning for a Universal Insurance Policy. This is particularly
significant because other medical associations have opposed medical reforms. As part
of the efforts to influence policy makers, the association has organised a national talk
show on television, interacted with local governors and are now planning to take the
issue directly to the people.
11.2
Inter-collegiate forum on Poverty and Health, U.K. (Iona Heath, U.K.)
In the past, the medical professionals have shown little interest in understanding the links
between poverty and ill health. The Inter-collegiate forum on Poverty and Health is
therefore a significant initiative that has reflected on the issues of Poverty and Health in
U.K., focussed on the growing inequalities and contributed to the policy dialogue in
U.K. The forum responded to the Acheson Report and emphasized that better quality of
life is more important than just saving lives. The forum is exploring the possibility of
becoming a national health watch.
11.3
Partnership with Business for Global Health (Olivier Giscard D’Estiang, France)
Representing the Business Association for the World Social Summit (BUSCO),
Mr. Estiang stressed the need to actively involve and tap the potential of ethical business
partners in initiatives to respond to the Global Health crisis. While business increases
productivity, helps to reduce the prices and eventually helps the consumer and creates
jobs, it should also be ethical. This included higher workers salaries, enforcement of a
minimum wage, strengthening unions, and involving the people in the benefits rather
than exploiting them. Business must also maintain its responsibility towards the
environment while trying to satisfy its employees and customers. For this it must be
more transparent. Reforms must come from within industry through active dialogue, not
just from regulation and rules.
11.4
•
Listening to the People (Charles Oyaya, Kenya)
There is need for academics to build their academic experience by building community
participation and listening to the people and how they talk and feel about their
experience of poverty. This will help us to develop new paradigms and to develop
specific and alternate strategies for poverty reduction. There is need to move beyond
‘income issue’ in poverty assessment and look at other issues of integrity and dignified
living. This will include factors such as a sense of belonging and spirituality.
39
11.5
Dialogues on Poverty and Health in Bangaldesh (Sharifa Begum)
The Bangladesh Institute of Development studies organised a dialogue on Poverty and ill
Health in Bangladesh, bringing together academics, researchers, NGOs, government
resource persons and others. The workshop suggested that rather than techno
managerial and purely bio medical solutions to public health problems, there is need to
look to broader social mobilisation. Tne workshop suggested that there should be,
® A people’s commission on Poverty and Health
® An effort to change medical education curriculum so that the medical profession will
be more sensitive and responsive to the issue of poverty and ill health.
® An effort to dialogue with representatives of governments and other sectors to
enhance intersectorality.
11.6
Some lessons from recent experiences of South-South dialogue (Devaki Jain, India)
Reflecting on some recent experiences of South-South dialogue including meetings of
women’s groups globally, Dr. Jain emphasised some key learning points, which
included,
® Public policy action must be linked with personal morality issues and to identify
with the poor we must restrain self-consumption.
® Dialogue must include an active sharing of information and strategies.
® We must identify existing agenda to them strategically.
® Regional efforts are an important way to deal effectively with globalisation
® We must stress the women’s lens while initiating effective public action.
® While South-South dialogue is a must, every effort-must be to get northern solidarity
and make northerners join issues of common concern.
11.7
The People’s Health Assembly, Dhaka 2000 A.D. (Dr. Zafarullah Chowdhury,
Bangladesh)
The People’s Health Assembly to be held in Dhaka in December 2000 is an effort by a
growing coalition of grassroot organisations and networks dedicated to health and
equitable development. The goal is to re-establish health and equitable development as
top priorities in local, national and international policy making, with Primary Health
Care as the strategy for achieving these priorities. The Assembly aims to draw on and
support people’s movements in their struggles to build up long term and sustainable
solutions to health problems. The PHA process is a collective effort in opening up
opportunities, drawing in communities and civil society organisations in their work
towards just and equitable health and health related policies for all.
The PHA process is an effort to listen to the voiceless. .The dialogue on poverty , ill
health and so on must move beyond definitions and frameworks to sitting down with
people to fmd way of spreading new ideas for action to achieve better health. WHO
consultants, academic, research groups and policy makers must be ready for this task.
The PHA may be an opportunity to get involved in such a process.
40
*
A lack of insight into the inter-sectoral nature of health problems and the
PEOPLE’S HEALTH ASSEMBLY: CONCERNS
Retreat from the goal of national health and drug policies as part of an overall
social policy.
!|
*
11.8
Towards an IPHN Action Plan
I
I
I
A small group which represented the IPHN Advisory Group met a few times during the
dialogue and tried to further clarify the emerging role of IPHN and the challenges ahead.
Some ideas evolved,
® IPHN is a group that aims to facilitate interaction on poverty issues
® IPHN is a group that will act as an advisory group (a facilitating group rather than an
action group)
® Actions should necessarily be taken up by the local people and local groups in a
country or region. It will be most effective when action comes from people where
they are. However, IPHN could link information through the internet and report it in
the media, wherever possible, to strengthen the efforts in solidarity.
® IPHN plans to facilitate a letter to the BMJ or an Editorial on the ‘Poverty and Health
-‘theme to spread the concern and stimulate action.
® IPHN would also try to mobilise political and economic resources from the north for
supporting the movements in the south.
® IPHN is glad to see that WHO and other agencies have supported the network process
from the very beginning. We need to move towards a separate Secretariat outside of
WHO to continue our facilitator role and take many emerging goals and issues
forward.
® IPHN must struggle to keep the Poverty and Health agenda on the top of International
concerns at all levels and increase the involvement of people from the North in these
concerns.
® IPHN should build on the rich experience of its members, learning from it and
proactively spreading it to others interested in similar concerns.
® IPHN should strive to facilitate the presence of the voiceless in the policy-making
efforts of international agencies in solidarity with the poor and marginalsied of the
world.
The South Asian Dialogue was an initiative of IPHN which addressed many of these ideas
quite effectively. Much more needs to be done in many other parts of the world.
41
12. STRATEGIES FOR ACTION : An Agenda for 2000 AD and
Beyond
The participants deliberated in five groups during the end of the dialogue to identify Strategies
for Action. Each group, each participant, each country and each region has to evolve its own
special agenda for 2000 AD and beyond. The following is a check list for all concerned :
12.1 Strategies for Change : Local / Community
Social mobilization and community diagnosis of and around risks and interventions
required.
Special attention and sensitization to the problems of the poorest sections.
“>
Sensitization ofInternational bodies of the ground realities.
■>
Reassertment of importance of Primary Health Care through Community Health
Workers, as several models in South Asia have proved.
Ensuring Right To Information.
Land Reform, recognising it as a crucial issue in poverty reduction and Health For
All initiative.
Ensurance of a Corruption free Society.
Understanding peoples needs and perceptions.
12.2
Strategies for Change : National Level
Ensuring people's participation at all levels of planning, implementation and
evaluating.
Integrating vertical programmes with the rest of the health care system.
Effective implementation of legislation empowering women.
12.3
■>
Strengthening public health services.
*>
Monitoring and regulating private health sector.
Strategies for Change: Regional / SAARC level
■>
Enhancing regional cooperation especially tackling problems especially flood,
malaria, water-disputes, that are commonly faced by SAARC countries.
•>
Sharing experiences within the region.
■>
Pressurizing SAARC heads to put health on their agenda through advocacy and
information.
■>
Health sector should build upon existing lobbying groups to address women's
issues
■=>
Active consideration of the concept of the entire SAARC region as one economic
block to maximise the regional economic potential.
42
12.4
Strategies for Change : WHO level
05
Increasing the number of non-medical professionals in WHO to balance the bio
medical tilt.
■>
A policy to ensure that WHO consultants spend more time in the field to observe for
themselves the reality.
Making various WHO publications more accessible by printing locally etc.
Community groups can be invited to the Assembly to influence the proceedings.
12.5
Strategies for Change : International Donor Agency level:
Policies and plans must be made by the recipient countries. At present there is lack
of transparency and lack ofpublic debates on the role of donor agencies.
■>
Let the question ofpoverty reduction be central to all discussions.
«>
Reduce dependence on international consultants.
Mobilize support from international communities.
Reemphasize comprehensive Primary Health Care.
■>
Demand accountability and transparency of the donor agencies.
END
43
© "Never before did mankind have
such formidable scientific and
technological potential,
such
extraordinary
capacity
to
produce
well being but never
before
were
disparity
and
inequity so profound in the world
© The 'New Economics' is like a ship
whose
85%
passengers
are
crowded
together
suffering
hunger, disease and helplessness
.... And destined to clash with an
iceberg
© Another 'Nuremberg' is required to
put on trial the economic order
imposed upon us.
The current
global system is killing by hunger
and preventable and curable
diseases, more men, women,
children every three years than
all those killed by world war II in
six years ....
Fidel Castro,
G-77 Meeting in Havana
13th April, 2000
44
Appendix - A
SOUTH ASIAN DIALOGUE ON POVERTY AND HEALTH
15lh to 18lh November 1999
Bangalore, India.
ADDRESS LIST OF PARTICIPANTS
THE SAARC COUNTRIES
BANGLADESH
1. Dr. Abul Barkat, Professor, Department of Economics, University of Dhaka, Dhaka1000, Bangladesh.
Tel: (880 2) 966 1516 (res); Fax : (880 2) 817 957; Email: urcbd@pradeshta.net
2. Dr. Sharifa Begum, Senior Research Fellow, Bangladesh Institute of Developmental
Studies, E-17, Agargaon, PO Box 3854, Sher-e-Bangla Nagar, Dhaka - 1207
Tel: (880 2) 9115 754 (off),(880 2) 8122512(res); Fax: (880 2) 8113 023;
Email: sharifa@bdonline.com
3. Dr. Qasem Chowdhury, Executive Director, Gonoshasthya Kendra, PO Nayarhat, Dhaka
1344.
Tel: (880 2) 933 2245; Fax: (880 2) 863 567; Email: gk@citecho.net
4.
Dr. Zafrullah Chowdhury, Gonoshasthya Kendra, H14E, Road 6, Dhanmondi, Dhaka
1205
Tel: (880 2) 861 7208 (off); (880 2) 811 1495 (res); Fax: (880 2) 861 3567, 861 6719
Email: gk@citecho.net
5. Dr. Naila Z. Khan. Dhaka Shishu Hospital, Sher-e-Bangla Nagar, Dhaka 1207
Tel: (880 2) 811 6061- Ext 401, 882 3185; Fax: (880 2) 882 6380 ;
Email: zakhan@banela.net
INDIA
6.
Prof. Debabar Banerji, Nucleus for Health Policies and Programmes, B-43, Panchsheel
Enclave, New Delhi - 110 017
Tel: (91 11)649 0851, 649 8538; Fax: (91 11) 649 8538;Email: nhpp@bol.net.in
7. Ms. Nimitta Bhatt, Trust for Reaching the Unreached, 210, Mangaldeep, Productivity
Road, Vadodara - 390 007 , Gujarat, India
Tel: (91 265) 338 117 ; Fax: (91 265) 331 627 Email: truguj@vsnl.com
8. Ms. Shilpa K Pandya, Insurance Coordinator, Self Employed Women’s Association,
SEWA Reception Centre, Opp.Victoria Garden, Bhadra, Ahmedabad - 380 001
Tel: (91 79) 550 6477, 550 6444 ; Fax: (91 79) 550 6446 ;
Email: sewa.mahila@gnahd.globalnet.ems.vsnl.net.in
9. Dr. Devaki Jain, Economist, D-5, 12th Cross, RMV Extension, Bangalore - 560 080
Tel: (91 80) 334 4113 ; Fax: (91 80) 331 2395 ; Email: Icjain@bgl.vsnl.net.in
10. Dr. Mohan Rao, Associate Proffessor, Centre for Social Medicine and Community
Health, School of Social Sciences, Jawaharlal Nehru University,
New Delhi - 110 067
Tel: (91 11) 619 6631 ; Fax : (91 11) 619 6630; Email: mohan@muniv.emet,in
E:\IPHN MEETTNG'PrococdingsXAppendix A.doc
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11.
Dr. Mira Shiva, Head, Public Policy Unit, Voluntary Health Association of India, Tong
Swast, 40, Institutional Area, Behind Qutub Hotel, South of IIT, New Delhi - 110016.
Tel: (91 11) 651 8071 /651 8072 (off), (91 11) 685 5010, 685 6795 (res.); ’
Fax: (91 11) 685 3708 ; Email: vhai@del2,vsnl.net,in
12. Mr. J Vunalanathan, New Entity for Social Action (NESA), 93\2, Charles Campbell
Road, Cox Town, Bangalore -560 005
Tel: (91 80) 548 3642, 548 7654 ; Fax: (91 80) 548 5134; Email:: nesa@vsnl.com
13.
Mr. Ravi Duggal, Coordinator, Centre for Enquiry into Health and Allied Themes
(CEHAT), BMC Maternity Home, Military Road, Near Lok Darshan Marol, Andheri
East, Mumbai - 400 059
Tel: (91 22) 851 9420 ; Fax: (91 22) 850 5255; Email: cehat@vsnl.com
14.
Dr. D.K. Srinivasa, 743, 13th Cross, 7th Block - West, Jayanagar, Bangalore 560 082.
Tel: (91 80) 665 8743; Fax: (91 80) 665 8569 ; Email: DRDKSRINIVAS@hotmail.com
15.
Mr. R. Gopalakrishnan, Secretary to Chief Minister and Coordinator, Rajiv Gandhi
Missions, Govt, of Madhya Pradesh, Mantralaya, Vallabh Bhavan, Bhopal - 462004,
Madhya Pradesh
Tel: (91 755) 551 386; Fax (91 755) 556 634; Email: gopalkr@bom6.vsnl.net.in
16.
Ms. Aodiiti Mehtta, Joint Sectratary, Prime Minister’s Office, South Block, New Delhi.
Tel: (91 11) 301 2613; Fax: (91 11) 301 9545, 301 6857; Email: aodiiti@pmo.nic.in
MALDIVES
17.
Ms. Fathimath Moosa Didi, Director General of Nursing, Ministry of Health, Ameenee
Magu, Male, Republic of Maldives
Tel: ( 960) 31 7203 ; Fax: ( 960) 32 8889, 320 520 ; Email: moh@dhivehenet.net.mv
NEPAL
18. Prof. Mathura P. Shrestha, P O Box 5625, Kathmandu, Nepal.
Tel: (977 1) 371 199 ; Fax: (977 1) 371 122; Email: mathura@healthnet,org.np
19. Dr. Aruna Uprety, Dilibazar, Pipalbot, P.O. Box 335, Kathmandu, Nepal
Tel: (977 1)419 899 ; Fax: (977 1) 225 675 ; Email: bbs@healthnet.org.np
PAKISTAN
20.
Dr. Mohammed AH Bar-gar - MOH, Hafez Avenue, Chahar Rah, Yousefabad, P.O. Box
11365, Tehran - 3599, Iran.
Fax: (0098) 21- 678 969;Email: wrotech@Farabi.hbi.dmr.or.ir
21.
Prof. A. Gaffar Biloo, 3 A- Justice Inanullah Road, Hill Park, Karachi - 74800
Tel: (92 21) 493 0051, 493 4722; Fax: (92 21) 493 4294; Email: gaffar.billoo@aku.edu
22.
Dr. Mohammed Yousuf Memon, Department of Community Health Sciences, Aga Khan
University, Karachi, Pakistan
Tel: (92 21) 493 0051-Ext- 4829; Fax: (92 21) 493 4294; Email: yousuf.memon@aku.edu
MEETING\Proceedings\Appendix A.doc
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S.RI LANKA
23.
Ms. Myrtle Perera, Executive Director, The Marga Institute, 93/10, Dutugemunu Street,
Kirulapone, Colombo - 6
Tel: (94 1) S29 012 ; Fax: (94 1) 82S 597 ; Email: Marga@sri.lanka.net
24.
Dr. Na da rajah Sivarajah, Faculty of Medicine, Jaffna University, Jaffna, Sri Lanka
Tel: (94 1) 212 068 ; Fax (94 1) 212 073 ; Email: uianatomy@eureka.lk (attn: Dr. N.
Sivarajah)
25. Dr. Mrs. Geethani Kandunduhewa, Community and Environmental Health Unit,
Sarvodaya, Moratuwa, Sri Lanka.
Tel: (94 1) 642 037; Email: geethani@sltnet.lk
NETWORKS
26. Dr. B. Ekbal, Chairman, Health Sub Committee, Kerala Sastra Sahitya Parishad,
Professor and Head, Department of Neuro Surgery, Kottayam Medical College, Kottayam
- 686 008, Kerala
Tel: (91 481) 597 555 (res), (91 481) 597 311 (off); Fax: (91 481) 598 284;
Email: ckbal@vstil.com
27.
Dr. Prem Chaiidran John, Coordinator, Asian Community Health Action Network, Post
Bag 1404, Chennai 600 105
Tel: (91 44) 823 1554 ; Fax: (91 44) 827 0424 ; Email: prem@md2.vsnl.net.in
28.
Mr. Geo Jose, National Alliance of People’s Movement India, 41/1771, Veekhanam
Road, Kochi 682 018, Kerala.
Tel: (91 484) 426 506; Email: inspire@md2.vsnl.net.in
29. Fr. John Vattaniattoni, svd, Sadbhavana, Post Box 9747, New Delhi - 110 025.
Tel: (91 11) 683 9248, 692 5080; Fax: (91 11) 691 0077;
Email: sadbhav@del2.vsnl.net.in
OTHER REGIONS
FRANCE
30. Mr. Olivier Giscard d’Estaing. President, Business Association for the World Social
Summit (BUSCO), 25, Bu du Chateau, F - 92200, Neuilly sur Seine, France
Tel: (33 1)46 24 34 38 ; Fax: (33 1)46 24 34 38 ; Email: Ogiscard@aol.com
KENYA
31. Mr. Charles Oyaya, Christian Health Association of Kenya (CHAK), P.O.Box 73860,
Waiyaki Way, Musa Gitau Road, Wsetlands, Nairobi, Kenya
Tel: (254 2) 441 046; Fax: (254 2) 440306 ; Email: tichnbi@net2000ke.com
REPUBLIC OF CONGO , COTE D IVORIE
32. Dr. Patricia Nickson, 89 Upton Park Drive, Upton, Wirral. CH49 6JW, England.
Tel: (44 151) 678 6681 ; Fax: (44 151) 707 1702; Email: ipasc@maf.org
E:\IPHN MEETTNG'Proccedings’-Appendix A.doc
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PERU
33.
Dr. Oscar Lgarte, Centro de Estudios y Promocion del Desarrollo, Calle Leon de la
Fuente 110. Lima 17, Peru
Tel: (51 1) 264 1316, 263 6005 ; Fax: (51 1) 264 0128 ; Email: ugartei7ydesco.org.pe
UNITED KINGDOM
34.
Dr. Roger Drew, Healthlink Worldwide, Farringdon Point, 29-35 Farringdon Road,
London EC1M 3JB
Tel: (44 171) 242 0606; Fax: (44 171) 242 0041; Email: drew ,r@healthl: ink.org.uk
35.
Prof. Andy Haines, Department of Primary Care and Population Sciences.Royal Freea
and University’ College Medical School, Rowland Hill Street,London NW3 2PF
Tel: (44 171) 830 2391 ; Fax: (44 171) 830 2339 ; Email: a.haines@ucl.ac.uk
36.
Dr. Iona Heath, Inter Collegiate Forum on Poverty and Health, Royal College of General
Practitioners, 14 Princes Gate, Hyde Park, London SW7 1PU, United Kingdom
Tel: (44 171) 581 3232, 226 1647 (W); Fax: (44 171) 359 4223 ;
Email: pe31@dial.pipex.com
37. Mr. Des McNulty, Member of the Scottish Parliament, Scottish Parliament Edinburgh
EH99 ISP, Scotland
Tel: (44 131) 348 5918; Fax: (44 131) 348 5978;
Email: Des.Direct@scottish.parliament.uk
UNITED STATES OF AMERICA
38.
Dr. Whitney Addington 2708 Lakeview Avenue, Chicago ILL 60614
Tel: (1 312) 942 8389 ; Fax: (1 312) 666 5709 ; Email: w.addingt@rush.edu
WHO HEADQUARTERS
39. Dr. John Martin, WHO 1211, Geneva 27
Tel: (41 22) 791 2728; Fax (41 22) 791 4153; Email: martin@who.ch
40.
Ms. Margareta Skold, WHO,Health in Sustainable Development,Avenue Appia 20, CH
1211, Geneva 27, Switzerland
Tel: (41 22) 791 2564; Fax: (41 22) 791 4153; Email: skoldm@who,ch
WHO - SEARO / SAARC
41.
Dr. Robert Kim Farley, WHO Representative to India, 534 “A” Wing Nirman Bhavan,
Room 533-35, ‘A’ Wing, Maulana Azad Road, New Delhi - 110 011
Tel: (91 11) 301 8955; Fax: (91 11) 301 2450;
Email: KIMFARLEY@COMPUSERVE.COM
42. Mr. B.S. Lamba, Health For All Officer, World Health Organisation - SEARO, World
Health House, Indraprastha Estate, New Delhi - 110 002, India
Tel:(91 11)331 7804; Fax: (91 11)331 8607; Email: lambab@whosea.org
WORLD BANK
43.
Mr. Richard Skolnik, World Bank, New Delhi Office, Lodi Estate, New Delhi -110 003.
Tel: (91 011)461 2741 /461 9491; Fax: (91 011)461 9393;
Email: Rskolnik@worldbank.org
E:\IPHN MEETTNG'.Procecdings'Appendix A-doc
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COMMUNITY HEALTH CELL TEAM OF FACILATORS
44.
’
Dr. C..M. Francis, Consultant, Planning and Management, Community Health Cell, 367,
‘Srinivasa Nilaya’, Jakkasandra, Is' Main, Is' block, Koramangala, Bangalore - 560034,
India
Tel: (91 SO) 553 1518 ; Fax: (91 80) 552 5372 ; Email: sochara@vsnl.com
45. Prof. Mohan Issac, Professor and Head, Department of Psychiatry, National Institute of
Mental Health and Neurological Sciences, Hosur Road, Bangalore - 560 029, India.
Tel: (91 80) 664 2121 -Ext- 2253/ 2052; Fax: (91 80) 663 1830;
Email: Isaacmohan@hotmail.com
46. Dr. Mani Kalliath, Team Leader, Advocacy, Community Health Department, Catholic
Health Association of India, P.O. Box 2126, 157/6 Staff Road, Gunrock Enclave,
Secundrabad - 500 003, Andhra Pradesh, India.
Tel: (91 40) 784 8457 ; Fax: (91 40) 781 1982 ; Email: chai@hdl .vsnl.net,in
47. Dr. Ravi Narayan, Community Health Advisor, Community Health Cell, 367,
‘Shrinivasa Nilaya’, Jakkasandra, 1st main, Is' block. Koramangala, Bangalore -560034.
India.
Tel: (91 80) 553 1518 ; Fax: (90 81) 553 5372 ; Email: sochara@vsnl.com
48.
Dr. Thelma Narayan, Coordinator, Community Health Cell, 367, ‘Srinivasa Nilaya”,
Jakkasandra, 1st main, T‘ block, Koramangala, Bangalore - 530034, India
Tel: (90 81) 553 1518 ; Fax: (90 81) 553 5372 ; Email: sochara@vsnl.com
RAPPORTEURING TEAM
1.
V.R. Muraleedharan, Associate Professor Of Economics, Indian Institute of
Technology, Chennai - 600 036
Tel: (91 44) 445 8431 (off), (91 44) 235 5026 (res); Fax: (91 44) 235 0509;
Email: vnn@acer.iitm.emet.in
Dr.
2. Dr. Sunil Kaul, 144, Akash Darshan, 12 Mayur Vihar -I, New Delhi- 110 091
Tel: (91 11) 225 3250; Email: sunilkaul@mantTaonline.com
3. Dr. K.R. John, Health Economist / Sr. Reader, Department of Community Health,
Christian Medical College, Vellore
Tel: (91 416) 262 603-ext- 4212(res)/ 4207(off); Fax: (91 416) 262 268
Email: iohn@cmc.emet.in
4. Dr. Joseph Williams, PO Box 1404, Asian Community Health Action Network, Chennai
-600 105
Tel: (91 044) 823 1554/821 1058; Fax: (91 044) 827 0424;
Email: madras.achan@axcess.net.in I prem@md2.vsnl.net.in
5. Dr. Unnikrishnan P.V., Oxfam Fellow - Emergencies, Oxfam (India) Trust, B-3,
Geetanjali Enclave, New Delhi - 110 017.
Tel: (91 011) 685 7052; Fax: (91 Oil) 618 646; Email: unnikru@nda.vsnl.net.in
E:\IPHN MEETING\Proceedings\Appendix A.doc
- V -
Appendix - B
Mh tea
©n
& fe»
WHO - Health in Sustainable Development,
International Poverty and Health Network Advisory Group,
Community Health Cell, Bangalore
15th to 18th November, 1999
Venue
National Institute ofAdvanced Studies (NIAS), Indian Institute of Science Campus,
Bangalore - 560 012, India.
PROGRAMME OF WORK
Date / Time
Programme Details
Sunday, 14"' November, 1999
Whole Day
•
Participants arrive in Bangalore
Accommodation at
1. National Institute of Advanced Studies
2. Hotel Ashraya International
7.00 p.m.
•
Welcome fellowship dinner with local organising team at
National Institute of Advanced Studies.
Monday 15"'November, 1999
-
COMMUNITY VISITS
8.30 a.m.
Briefing on Community visits by the CHC Team. All
Participants gather at Hotel Ashraya International.
9.00 a.m. to 4.00 p.m.
COMMUNITY VISITS
Group
A/
W
.
Nature of Organisation
Group One
Bonded / Child Labour Jeevika, Anekal.
Group Two
Urban Slum / Street Children Association for Promoting Social Action
Namma Mane, Indira Nagar
Group Three
Indigenous People Ramana Maharishi Academy
Grama Rakshe, Kanakapura
Project,
Group Four
People with Disabilities Association for People with Disability
Lingarajapuram and Sriramapuram
Group Five
Women’s Health and Development St. John’s Medical College, Mugalur
Project, Mugalur
Group Six
Corporate Sector Initiative Titan Industries, Hosur
See separate note with furtiter details
■ The visits will get over at different times, after which the participants will return to their hotel and NIAS
E:'JPHNMEztlXGEroceedings\.4ppendix B.doc
Date / Time
Programme Details
6.00 p.m. to 7.30 p.m.
Learning from the Community - Short reports by the 6
Groups on Key Learning Experiences followed by
discussion.- At NIAS
8.00 p.m.
Welcome Dinner (informal) at NIAS
Tuesday 16,n November, 1999
8.30 a.m. onwards
Registration of Participants
9.00 a.m. to 10.00 a.m.
INAUGURATION
Chairperson :
Dr. Chandhrashekara Shetty, Vice Chancellor, Rajiv Gandhi
University of Health Sciences, Bangalore.
Co Chairperson:
Dr. C.M. Francis, Consultant, Community Health Cell, Bangalore
9.00 a.m. to 9.05 a.m.
o
Welcome to Symposium and Dialogue :
Community Health Cell - Dr. Thelma Narayan
9.05 a.m. to 9.10 a.m.
o
Inauguration with lamp lighting
9.10 a.m. to 9.25 a.m.
o
Inaugural Reflections
Dr. Chandrashekara Shetty, Vice-Chancellor
Rajiv Gandhi University ofHealth Sciences
9.25 a.m. to 9.55 a.m.
o
Introductory Remarks
•
National Institute of Advanced Studies Dr.
Roddam
Narasimha
•
•
«
9.55 a.m. to 10.00 a.m.
o
Government of Karnataka - Mr. Abhijith Sengupta
WR - India- Dr. Robert Kim Farley
WHO - HSD - Dr. John Martin
Vote of Thanks
Coffee / Tea
10.00 a.m. to 10.30 a.m.
10.30 a.m. to 1.00 p.m.
Symposium:
Poverty and Health In South Asia: Crisis and Challenge.
Chairperson : Dr. Devaki Jain
Co Chairperson : Dr D.K. Srinivasa
Speakers :
o
10.30 a.m. to 11.00 a.m.
Keynote Addresses:
1.
Poverty, Disease and National and International Power
Structure — The Case of India
Prof. Debabar Baneiji, Nucleus for Health Policies and
Programmes, New Delhi, India.
11.00 a.m. to 11.20 a.m.
2.
Poverty and Health - Reflections from Bangladesh
Dr. Zafrullah Chowdhury, Gonoshasthya Kendra,
Bangladesh.
E: \1PHN MEETTNG'Proceedings Appendix B.doc
- vii -
Date / Time
Programme Details
Tuesday 16th November, 1999 (Contd.)
11.20 a.m. to 12.10 p.m.
o
Discussants :
I.
Poverty and Development Paradigm - Peoples
Perspective
Dr. Mathura Shrestha, Nepal
2.
Equity in Health Care - A Formidable Challenge
for Sri Lanka.
Ms. Myrtle Perera, Sri Lanka
3.
Poverty and Health towards Equity and Poverty
Eradication - Reflections.
Dr. Yousuf Memon, Pakistan
4.
Crisis of Governance
Bangladesh.
in
Public
Health
Dr. Abul Barkat, Bangladesh
5.
A WHO Perspective
Dr John Martin, World Health Organization
12.10 p.m. to 12.30 p.m.
o
Questions from the Floor
12.30 p.m. to 1.00 p.m.
o
Chairperson's Remarks
Lunch ( Greenhouse - NIAS)
1.00 p.m. to 2.00 p.m.
2.00 p.m. to 4.00 p.m.
Session /.•
Chair
: Dr. Mathura
Shrestha
• South Asian Dialogue : Orientation
Co Chair
: Ms. Fathimath
Moosa Didi
» Expectations and Issues : A Group Inventory
Dr. Ravi Narayan, Community Health Cell, Bangalore
All Participants
o
IPHN overview : Ms Margareta Skold
4.00 p.m. to 4.30 p.m.
4.30 p.m. to 6.30 p.m.
Tea / Coffee
Croup Discussions 1:
Exploring the Poverty and Health Framework
Group
E:\IPHN MEETIXGPrvceedings\Appendix B.doc
Topic
I
Socio Economic Deprivation and Ill Health
II
Ill Health leading to Poverty
III
Feminization of Poverty •
IV
Globalization and Health
V
Poverty, Ecology and Health
VI
Disaster, Poverty and Health
- viii -
-
Date / Time
Programme Details
Wednesday 17th November, 1999
8.30 a.m. to 10.00 a.m.
Chair
Co Chair
Session //.•
: Dr. Patricia
Nickson
• Listners Reflections on previous day’s proceedings
•
Plenary : Short report of Group Discussions
Dr. Naila Z.
Khan
Discussion
Tea / Coffee
10.00 a.m. to 10.30 a.m.
10.30 a.m. to 12.00 Noon
Chair
Co Chair
: Dr. B. Ekbal
Dr. Oscar
Ugarte
Session ill:
Global, Regional,
Poverty and Health
o
National Concerns impacting on
Discussants :
•
•
Globalization - Dr. Prem John
WTO & Health Agenda of Third World Countries •
Dr. Mohan Rao
•
IPR & Commodification of Health - Dr.
Mathura
Shrestha
•
Privatization and Health - Dr. Ravi Duggal
•
War, Poverty and Health - Dr. Sivarajah
»
Breakdown of Public Health Systems - Dr.
Mani
Kalliath
•
Neglect of Traditional Systems of Health Care -
Fr. John Vattamattom
•
Implications ofInternational Collaboration -
Dr. Ravi Narayan
•
12.00 Noon to 1.15 p.m.
Chair
: Mr. Gopala
Krishnan
Co Chair
: Dr. Iona Heath
Any other
Session IV:
Health and Poverty Eradication Perspectives of World
Bank and WHO
o
Presentations:
• Mr Richard Skolnik, World Bank
• Dr. John Martin, WHO
Discussion
1.15 p.m. to 2.15 p.m.
E:\IPHN MEETINGProceedings\Appendix B.doc
Lunch
- ix -
Date / Time
Programme Details
Wednesday, 17th November, 1999 (could.)
2.15 p.m. to 4.00 p.m.
Chair
: Mr. Oliver
Giscard
d’Estiang
Co Chair
: Mr. Charles
Oyaya
Session V:
Health and Poverty Eradication : Action Initiatives and
Strategies - Local, National and Government, NGO
o Discussants (8 minutes each)
•
The Sarvodaya Initiative (Sri Lanka) - Dr. Geethani
Kandaudahewa
•
Gonoshasthya Initiatives (Bangladesh) - Dr Qasem
Chowdhury .
• NGO initiatives in Pakistan (Pakistan) -
Prof
Gaffar Biloo
•
National Alliance of Peoples Movements (India) -
Mr. Geo Jose
•
The SEWA ExperiencefGujarat, India) - Ms Shilpa
Pandya
« Peoples Participation (Maldives') -
Ms Fathimath
Moosa Didi
•
Community Health Service Guarantee Scheme
(Madhya Pradesh, India) - Mr. Gopalakrishnan
»
Decentralised Health Planning (Kerala, India) -
Dr. Ekbal
» Any other
Tea / Coffee
4.15 p.m. to 4.30 p.m.
4.30 p.m. to 6.30 p.m.
Croup Discussions // :
Equity in Health and Poverty Eradication : What
Strategies can be initiated?
Group
Level
I
Local / Community
II
National
III
Regional 1SAARC
IV
WHO
V
International Donor Agencies
IPHN Advisory Group may meet concurrently
7.30 p.m. to 8.30 p.m.
8.30 p.m.
E: -JPHN MEETINGProceedings'Jppendix B.doc
Cultural Evening - NIAS Auditorium
Dinner at NIAS
-X -
Date / Time
Programme Details
Thursday 18rh November, 1999
8.30 a.m. to 10.00 a.m.
Chair
: Mr. Des
McNulty
Co Chair
: Dr. Aruna
Uprety
.
Session Vl :
Strategies for Change
•
Listners Reflections on previous day’s proceedings
®
Plenary : Short report of Group Discussions II
Discussion
10.00 a.m. to 10.30 a.m.
Tea / Coffee
10.30 a.m. to 12.00 Noon
Session VII:
Chair
: Dr. Debabar
Banerji
Policy issues for Equity' in Health and Poverty Eradication
-Implication for WHO / IPHN
Co Chair
: Dr. Roger
Drew
o Discussants
• Strengthening Civil Society - Dr. Iona Heath
o Intersectoral Action - Dr. Andrew Haines
o Powerlessness and Empowerment - Dr. Patricia Nickson
o Politics of Health Policy Implementation - Dr. Thelma
Narayan
• Research Priorities - Dr. Sharifa Begum
• Humanpower Development- Dr. D.K. Srinivas
o Role ofPrivate Practitioners - Ms. Nimitta Bhatt
• Basic Minimum Needs Programme - Dr. Barzgar
o Any other
12.00 Noon to 1.15 p.m.
Session vin :
:
Mr. B.S. Lamba
O South-South and' North-South Dialogue and Experiences
beyond the SAARC Region : Participants
Co Chair :
Dr. Mohan Issac
O Peoples Health Assembly 2000 - Dr. Zafrullah Chowdhury
Chair
Lunch
1.15 p.m. to 2.00 p.m.
2.00 p.m. to 3.00 p.m.
Session IX:
Dr. Whitney
Action Plan : 2000 AD and Beyond
Addington
(An IPHN Core group will collate ideas through the meeting and present
: Dr. Prem John an IPHN Development and action plan for consideration by the dialogue
:
Chair
Co Chair
participants)
Tea / Coffee
3.00 p.m. to 3.30 p.m.
3.30 p.m. to 5.30 p.m.
Chair
:
Dr. V. Benjamin
Concluding Session:
o South Asian Dialogue : Statement and Action Plan Steering Committee
o IPHN Action Plan - Core Group
o WHO- HSD concluding remarks
o Reflections by some participants
o Wrap up and Thanks
E:'JPHN MEETING'J>roceedings\Appendix B.doc
- xi -
Appendix - C
COMMUNITY VISITS Community visits are being organised at six different project initiatives in
and around Bangalore. These are Health / Development and Poverty
alleviation programmes organised by Voluntary Agencies (NGO’s); a
Medical College and a Corporate Sector initiative.
© The six options are
Group One :
Jeevika Vimukti Trust, Anekal, A Programme to
tackle Child Labour including bonded Child Labour.
Group Two :
Association for Promoting Social Action (APSA) Slum Outreach Programme and Street Children Support and
Rehabilitation, Bangalore.
Group Three:
Gram Rakshe,
Extension programme among
indigenous people (Lambanis), Kodihalli of the Sri Ramana
Maharshi Academy of the Blind.
Group Four :
Urban Slum Outreach Programmes of the Associaton
of People with Disabilities, APD.
Group Five :
Mahila Vikas Project, Mugalur
Development Project) of Department
{Rural
Women's
of Community
Health, St. John’s Medical College.
Group Six
:
A
Corporate
Sector
Community
Development
initiative in villages around Bangalore.
© The aim of these community visits is to :
to the experiences of people living in the community,
especially the poor and the marginalised, regarding their
. experiences of poverty and ill health.
Listen
E:\IPHN MEETINGiProceedingMppendix Cdoc
- xii -
-
Learn how they cope with this situation and what they think of
existing governmental and non-governmental initiatives in health
care and poverty alleviation.
-
Identify how the Network, WHO, and International Agencies could
strengthen community initiatives at local level, through support to
governmental / non governmental initiatives.
© A short briefing will be organised at the Dialogue venue on 15th
November, from 9 to 10 a.m. Each group will consist of 6 - 8
members, accompanied by a CHC team member and a team member
from the NGO / institution hosting the community visit, who will
facilitate / translate.
The community visits will be between
10.00 a.m. and 4.00 p.m. (the timing will vary depending on travel
time and other logistics). Each group will share a meal with the local
hosts / community.
© Each group will discuss their learning experiences and share it in a
special session focussing on ‘Learning from the Community’.
O
All participants are requested to indicate which group they would like
to join. In case a group gets too large the organisers may have to use
their discretion to balance the groups.
© Each Community Visit option focusses on one deprived/marginal
group in the community. A more detailed background note will be
available for each visit and will be circulated during the briefing along
with some questions.
© CHC Staff and associates accompanied each group as facilitators /
translators.
tCHCj
r
E:\1PHN MEETlNGlProceedings\Appendix C.doc
- xiii -
Appendix - D
Poverty and Health in Developing Countries (especially
SAARC region)
Bibliography
This includes all the materials, papers and reports received by CHC during the interactive planning dialogue
preceding the South Asian Dialogue on Poverty and Health in Bangalore 15-18"' November, 1999.
(* indicates documents circulated with our correspondence or handed in the participant's pack).
1. * Agarwal A. The poverty of Amartya Sen. Down To Earth, December 15 1998.
2.
* Ariyaratne V. An Integrated Approach to Community Health: The Sarvodaya Experience in Sn Lanka,
March 1997, Sarvodaya.
3.
Bagchi A K. Amartya Kumar Sen and the Human Science of Development, Economic and Political
Weekly, December 5,1998:pp3139-3150.
4.
Banerji, D. Access of the Poor to Health Services in a Globalising Economy and Polity. Background
paper for Asian Community Health Action Network Meeting, March 1998, Bangkok.
5.
* Banerji D. Poverty, Disease and National and International Power Structure: The Case of India.
Keynote Address at symposium on Poverty and Health, Bangalore, 15-18 Novemberl999.
6.
* Barkat A. Crisis in Governance of Public Health System in Bangladesh: A Challenge for Sri Lanka,
paper prepared for South Asian Dialogue on Poverty and Health, Bangalore, 15-18 November
1999.
7.
Barkat A. Governance of Public Health in Bangladesh (Chapter 15), in Sobhan R(ed.) Crisis in
Governance, A Review of Bangladesh's Development - 1997,1998 Centre for Policy Dialogue,
University Press Limited, Dhaka.
8.
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Enterepreneurs presented to World Summit of United Nation for Social Development,
Copenhagen, 11-12 March, 1995.
9.
Carrin G and Politi C. Exploring the health impact of economic growth, poverty reduction and public
health expenditure, Macroeconomics, health and Development series, No 18, March 1996, WHO,
Geneva.
10. Carrin G and Politi C. Poverty and Health - An overview of the basic linkages and public policy
measures, Health Economics Technical Briefing Note, January 1997, WHO, Geneva.
11. * CHAI. Community Health: Search for New Paradigm, Health Action, vol 12, no.11, November 1999,
Health Action Trust, Sec'bad.
12. CHAI. Poverty: The ruthless killer - a symposium compilation, Health Action (special 100th issue) Vol.
9 No. 4, April 1996, Health Action Trust, Sec'bad.
13. Chowdhury Z. Poverty and Health: Lessons from Bangladesh, paper prepared for symposium at
South Asian Dialogue on Poverty and Health, Bangalore, 15-18 November 1999.
14. * Duggal R. A New Health Policy for Health Sector Reforms, Sep 1999.
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15. * Ekbal B. People’s Campaign For Decentralised Planning And The Health Sector In Kerala, paper from
the Nucleus for Health Policies and Programmes, New Delhi prepared for South Asian Dialogue on
Poverty and Health, Bangalore, 15-18 November 1999.
16. Feuerstien M. Poverty and Health - Reaping a Richer Harvest, 1997, Macmillan, London.
17. Goonatilleke G. Poverty and Health in Developing Countries and the potential role of technical
cooperation among developing countries (TCDC)for the poverty alleviation and health development,
Macroeconomics, Health and Development Series, No 16, May 1995, WHO, Geneva.
18. * Gopalakrishnan R. Strengthening Community Based Health Care in Madhya Pradesh through
Decentralised Management of Health Services, prepared by the Rajiv Gandhi Mission for the
Government of Madhya Pradesh.
19. * Government of Madhya Pradesh, Report on four years of Rajiv Gandhi Missions 1994-1998.
20. Haines A. Poverty and World Health: Challenges and Opportunities. J Epidemiol Community Health,
1999: 53: 0-1
21. Haq M. Development By People: Civil Society Initiatives, in Haq M, Human Development in South
Asia, 1997 HDC/Oxford Pub., Oxford.
22. Heggenhougen, K. Are the Marginalized the Slag Heap of Economic Growth and Globalization?:
Disparity, Health and Human Rights. Health and Human Rights Vol. 4, No.1,1999.
23. Holmberg J. Poverty, Environment, Development: Proposals for Action. Paper prepared for the
Secretariat of the 1992 UN Conference on Environment and Development, May 1991.
24. * IPHN news, International Poverty and Health Network, Issue 1, November 1998
25.
* IPHN news, International Poverty and Health Network, Issue 2, March 1999
26.
IPHN news, International Poverty and Health Network, Issue 3.
27.
* Jain D. Relevance of Ideas and Mass Mobilisation for the Removal of Poverty and Inequality, 1998,
SANGOCO, South Africa: pp 63-67.
28.
* Jain D. The Role Of People's Movement In Economic And Social Transformation, presented at 1999
Seoul International Conference of NGOs, 10-16 October 1999, Seoul, Korea.
29.
* Jain D. Nuancing globalisation or Mainstreaming the downstream or Reforming Reform: as you like it,
prepared for the Nita Barrow Memorial Lecture, Barbados, 12 November 1999.
30.
Kathuria S, Hanson J et al, India: Comprehensive Development Review of Policies to Reduce Poverty and
Accelerate Development Report No. 19471-IN, (confidential) June 1999, World Bank Poverty
Reduction and Economic Management Unit, South Asia region.
31. * Kaul S. Poverty and Health: Universal Abuse of Human Rights, unpublished.
32. Kaul S. Globalisation and Conflict: A Need for Primary Prevention, unpublished.
33. Kirby M. The Right to Health 50 years on: Still Skeptical Health and Human Rights. Vol. 4 No. 1, Jan
1999.
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34. Lamba, B.S. Notes on Health and Economic Growth. Evolution in thinking in development. 1997,
personal notes.
35. Lamba, B.S. Notes on Poverty - Health Interlinkages: Policy Implication, personal notes.
36. Lamba, B.S. Notes on Poverty in South Asia: The Global Face of Poverty, personal notes.
37. * Lamba, B,S. Notes on Poverty in India : Options for Alleviation, "The Fall of Poverty in India,"
1999:research for World Development Report 2000.
38. Lamba, B.S. Notes on Civil Society's Initiatives: Bangladesh, 1999, personal notes.
39. Lipson D J. Poverty and health: aligning sectoral programmes with national health policies.
Macroeconomics, Health and Development Series, No29, April 1998 ,WHO, Geneva.
40. * Marga Institute. Poverty and Health: Regional Issues - South East Asia, July 1997
41. WHO SEARO, New Delhi.
42. Mathiyazhagan, K. Willingness to pay for Rural Health Insurance through Community Participation in
India, 1998 Inter J of Hlth Plann and Mgmt.13, 47: 67.
43. • McCally M et al. Poverty and III Health: Physicians can and should make a difference. 1998. Annals of
Internal Medicine, Vol. 129, No. 9.
44. Memon Y. Social Development Initiatives in Pakistan by the Aga Khan University, presentation
prepared for South Asian Dialogue on Poverty and Health, Bangalore, 15-18 November 1999.
45. * MMI. Contracting NGOs for Health, Medicus Mundi International, Brussels.
46. Nyong'o P A. Poverty, Environmental Degradation and III Health in Sub Saharan Africa. Paper
prepared for Advisory Group of IPHN Kisumu, Kenya, November 1998.
47. Nyong'o P A. Viable Alternative Approaches To Meeting The Health Needs Of The Poorest And The
Most Vulnerable: The African Experience. Paper for WHO conference on "Meeting the health needs
of the poorest and the most vulnerable," Dhaka, Bangladesh, 11-13 April 1999
48. * Perera M. Equity in Health Care: A Formidable Challenge for Sri Lanka, paper prepared for South
Asian Dialogue on Poverty and Health, Bangalore, 15-18 November 1999.
49.
Robins S, Inequities in Health. Occasional paper, 1995, British Medical Association, London.
50.
Sainath, P et al. Dregs of Destiny, Cover story, Outlook, October 19.1998:pp 60-80.
51.
* Sen A. Health in Development, Keynote Address to Fifty Second World health Assembly, May
1999, WHO, Geneva.
52. Sen B. Health and poverty in the context of country development strategy: a case study on Bangladesh,
Macroeconomics, Health and Development Series, No 26, November 1997, WHO, Geneva.
53. Sen B and Begum S. Methodology for identifying the poorest at local level, Macroeconomics< health and
development series, No 27, February 1998, WHO, Geneva.
54. Sen B. Explaining Slaw Progress in Human Poverty Reduction in South Asia, first draft circulated for
presentation at South Asian Dialogue on Poverty and Health, Bangalore, 15-18 November 1999.
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55. * Shrestha M. and Shrestha I. Poverty & development paradigm- People's perspective, paper prepared
for South Asian Dialogue on Poverty and Health, Bangalore, 15-18 November 1999.
56. Shrestha I and Shrestha M P. Making Health A Public Agenda: Beyond advocacy to the common
concerns for all, Khoj-Bin - J Nep Hlth Res Council, 1997; l(l):15-20.
57. * Sivarajah N, Health and Poverty in War, paper prepared for South Asian Dialogue on Poverty
and Health, Bangalore, 15-18 Novemberl999.
58. Skold M. Poverty and health: who lives, who dies, who cares? Macroeconomics, Health and
Development series, No 28,1998, WHO, Geneva.
59. * Smeeth L and Heath I. Taki: :g Health Inequalities in Primary Care, Editorial, BMJ, 1999:318;1020-21.
60. UNDP, People's Participation, the South Asia Poverty Alleviation Programme (SAPAP) in the Maldives,
1999, UNDP, Male.
61. ‘ VHAI. People living below the poverty line, Health For The Millions, Nov-Dec 1998, Vol 24, No. 6
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‘ WHO. Final Report of the meeting on policy oriented monitoring of equity in health and health care,
Geneva, September-October 1997 SID A-WHO, Geneva - Executive summary.
63.
* WHO. International Poverty and Health Network, Advisory Croup Meeting Report, Kisumu and
Nairobi, Kenya, November 1998, WHO, Geneva, 1999.
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* WHO. Report of consultation on Equity and Health in South East Asia: Trends, challenges and future
strategies, Thimpu, Bhutan, November 1998 Equity initiative, Paper No 6, WHO, Geneva - Executive
summary.
65. * WHO. Unified call to fight poverty in To Our Health, No. 4, 21 May 1999, WHO, Geneva.
66. * Wignaraja P and Sirivardana S. Pro-Poor Planning through Social Mobilisation in South Asia,
extracts published in The Hindu Magazine, 26 July 1998.
67. World Bank. Poverty, Health Status and Health policy to reduce pauerfy(Chapter 3) in World Bank
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Washington DC.
68. South- South Solidarity, India and Resource Centre for Primary Health Care, Nepal.Emerging
Health Trends in South Asia: Global and National Responses for the Next Century, Round Table
Conference, 26-28 June 1999, Dhulikhel, Nepal.
(NB: Documents at serial no. 9,10,17,39, 52, 53 and 58 are available with WHO-HSD, Geneva, and
are available on request)
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