Health Cooperation Papers Quaderni di Cooperazione Sanitaria Poverty, Health & Development
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Health Cooperation Papers
Quaderni di Cooperazione Sanitaria Poverty,
Health & Development - extracted text
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Health Cooperation Papers
Quaderni di Cooperazione Sanitaria
Poverty,
Health & Development
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CONTENTS
Foreword, Enzo Venza
p-
5
Introduction
p-
7
PROCEEDINGS OF THE INTERNATIONAL WORKSHOP ON POVERTY, HEALTH AND
PART I:
DEVELOPMENT
11
pOpening address, Enzo Zecchini
12
pIntroduction to the workshop, Sunil Deepak —
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15
p
Poverty & Development - The Global Context. Mira Shiva
Poverty & Identifying the Poor, Usha S. Nayar
Strategies to Reach Disadvantaged Groups in Society, Maya Thomas
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25
p
35
Identifying the Poor - Group Discussions
Equity & Access to Health & Social Services. Chiara Castellani
p
40
p
43
Equity & Access in Health - Group Discussions
Understanding & listening to the Voices of the Poor, Mira Shiva
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52
P
56
The Voices of Disabled Persons, Claudio Imorudente
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66
Understanding & listening to the Voices of the Poor - Group Discussions
69
Poverty, Development and Health - Final Document
73
Participants in the Workshop
Workshop Programme Summary
74
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PART II: EQUAL OPPORTUNITIES FOR ALL: PROMOTING CBR AMONG URBAN POOR
POPULATIONS
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77
p
78
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Globalisation: A War Against Nature & People of the South, Vandana Shiva
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91
Follereau Would Say Today, Alex Zanotelli
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109
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113
Health for All Through - Leadership & Social Conscience, Halfdan Mahler
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118
Accessibility of Health Services in Nepal. Sarmila Shrestha
P-
123
Rich & Poor Theories of HIV Transmission. Stephen F. Minkin
P-
129
Reaching the Poorest & Disadvantaged Peculations, Thelma Narayan
p.
133
Experiences from the Field in Tanzania. Mwajuma S. Masaigapah...
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140
p.
144
Foreword
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Final Document
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List of Participants ............................
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PART III: POVERTY, HEALTH & DEVELOPMENT - OTHER ARTICLES
Marginalization: Cause and Effect of Poveny, Farhat Rehman
Gene Research - Myths and Realities, Danela Conti................
ANNEX
People’s Health Assembly and People’s Charter of Health
List of Authors
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Reaching the Poorest &
Disadvantaged Populations’
Thelma Narayan
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INTRODUCTION
The past century has seen an overall
decrease in infant and child mortality,
increased longevity, the global eradication
of smallpox, and the control of major
infectious diseases, particularly in some
parts of the world and in certain social
classes. Improved socio-economic
conditions and living standards, including
better housing and nutrition; public health
measures; education; and increased access
to medical and health care, are the major
causal factors. Developments in medical
science and technology and important
societal shifts underlie some of the changes.
The latter includes participatory democracy,
which has increased opportunities for pre
viously powerless sections of society, and
recognition of the basic human right to
health and health care based on social
justice, among others.
However at the start of the new millennium,
long-standing and yet unresolved
challenges remain. They include the
continuing health divide between the rich
and poor; between and within countries; the
gap between expected outcomes and
reality; implementation gaps in health pro
grammes; and disparities in control over
decision making concerning health,
between the powerful and powerless.
Paper presented at Medicine Meets Millenr jHannover, Germany, 2000
We need to shift attention from just reach
ing the poor and disadvantaged, which
implies merely an extension of the existing
paradigm, to understanding issues of
poverty, inequality and health, and to less
visible yet strong, underlying societal and
behavioural processes, which call for fresh
approaches and paradigms. As we ‘cease
our endeavours fora short while, to reconsider
and redefine our goals for the future' (MMM,
2000), which is one of the objectives of this
conference, we need to re-vision our
understanding of ‘self as a profession and
our relationship with the ‘other’, particularly
the poor in society, recognising the deeper
oneness and unity between us and them.
In reaching out to the poor, and in
addressing poverty, we help ourselves.
From a traditionally privileged position, in
creasingly subject to public scrutiny and
debate, the health profession can build on
Ts strengths and knowledge base,
especially with insights from the social
sciences, to increase its social
accountability and work in partnership with
ethers, especially the poor, towards Health
for All, Now! (Health for All, Now! is the
slogan of a peoples health campaign
-nderway in many countries, with a
Peoples Health Assembly (PHA)
erganised in December 2000)
World Congress on Medicine and Health,
133
CLARIFYING WORDS, REC
OGNISING SHIFTING
BOUNDARIES
The Poor - Social Minority or Majority?
varies. Those just above the poverty line
fall below it during periods of illness, r
adverse seasons, during natural calamities
social and political unrest, conflict etc. The
gap between rich and poor is widening in
Critical to the theme of this paper are
countries where economic liberalisation is
underway (PHA, 2000). While absolute
perceptions of the poor, and their role cagency in transformatory, chance
processes, towards better health and life r
all its fullness, as participant key subjects
rather than objects. The word marginalisec
is often used alongside ‘poor anc
disadvantaged ’. This suggests sma.
numbers or minorities at the margins c*'
mainstream society, who are left out anc
need to be reached. Knowledge, gainec
through research and experience of working
outside hospitals, suggests that numbers
are much larger, comprising perhaps the
social majority. ‘Impoverishment’, another
word, suggests that social and political
processes occur, making people poor.
poverty with a lack of resources, necessary
for survival, is associated with poor health
evidence from U.S.A, and U.K. indicate that
relative poverty, defined in relation to
average resources available in a society, is
also a major determinant of health (McCally.
1998). While the poor are sub-classified into
being destitute, very poor, very poor and
poor, ill health lowers access to good quality
health care, and ill-treatment by health
providers, are common experiences for the
entire group.
Poverty is also defined in contemporary
times "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
Measuring the magnitude of persons living
in poverty, through poverty lines, is
dependent on how poverty is defined.
Income poverty or food poverty lines
(measuring purchasing capacity for basic
Given the broadened definitions, which are
caloric requirements as in India) represent
a minimal, static and even arbitrary
required when using a value base of social
justice, there is evidence that a substantial
approach, resulting in lowered estimates
(Ghosh, 1990). The basic minimum needs
approach (including requirements for
clothing, shelter, medicine and schooling)
and the Physical Quality of Life Index (PQLI)
are other instruments. More recently the
multi-dimensional Human Poverty Index
(HPI) is a composite of longevity (life ex
pectancy), knowledge (literacy), economic
provisioning and social inclusion
(employment) (UNDP 2000). Distributional
disparities occur between gender, rural and
urban areas, region, ethnic and language
groups. Incidence and intensity of poverty
134
respect of others" (UNDP 1997).
proportion of the global population, live in
poverty, with different degrees of
deprivation, alienation and social exclusion.
In India, the proportion below a minimal
poverty line declined slowly from 50% in
1951 to 35% in 1994, but due to population
growth (which is also dependent on social
development), the actual number increased
from 164 million to 312 million. Recent
surveys of rural households show 68% as
landless wage earners and 45% of house
holds without anyone literate (cited in
Lamba. 1999). In 1998-99 in India, among
children under age three, 46.7% were
underweight (weight for age), 44.9% stunted
(heightforage) and 15.7%wasted (weight
for height) (NFHS2,2000). Among women
aged 15-49 years, 51.8% were anaemic
(ibid.).
This evidence along with several other
studies, indicates that a much larger
proportion of people suffer from depriva
tion, be it food, education or biological
poverty, than indicated by income poverty
lines, which are now below 30%. Thus it is
suggested that the poor in India and.
globally comprise a social majority (Pinto,
1998).
Doos this make a dlfleronco to our
strategies?
What is being reached - Health and/or
Medical care?
Increased provision of medical care reduces
unnecessary pain and suffering, but in itself
only marginally improves health status.
WHO defines health as a state of physical,
mental and social well being, and not
merely the absence of disease or infirmity.
Attempts to improve health status, towards
reaching this ideal, have long recognised
the importance of access to basic
determinants of health, such as nutrition,
safe water, sanitation, clean air, housing,
employment, safely at home, In the work
pluco and on IIio rondti. Social Inequality
deprives the poor of these basics. Is the
medical and health profession interested in
just medical care or also better health?
The WHO-UNICEF declaration in Alma Ata
in 1978, on Health for All (HFA) by 2000
through the Primary Health Care (PHC)
approach, used social justice as its basis
and explicitly adopted intersectoral
coordination as a strategy to address the
need for access to basic determinants of
health. The role and scope of the health
profession and health sector was thus even
then broadened beyond medical care. This
was mandated and accepted by all WHO
member countries, and followed up by
resolutions, national health policies, plans
and programmes. This was seen as an ad
vance in improving the health of the poor.
Very soon however this broad based
approach was narrowed down, selectivised
with vertical single disease programmes,
and medicalised with a focus on diagnostics
and drugs, not on people, communities and
society.
In 2000, while WHO busied itself with Safe
Blood as the theme of Its WHO Day, on 7,h
April, impoverished peoples and civic
society networks and movements in India
pledged, through a national campaign, to
continue to work with greater urgency
towards Health for All, Now! This is part of
a wider international peoples health cam
paign, leading to a Peoples Health
Assembly in Dhaka in December 2000,
which asserts that Peoples Health should
be in Peoples Hands and reaffirms the role
of the state in primary health care and public
health (PHA, 2000). At the turn of the mil
lennium we need to be analytical and
remind ourselves of the reasons that
prevented Health for All, through Primary
Health Care, from becoming a reality.
STRATEGIC APPROACHES
TO IMPROVED HEALTH
FORTHE POOR
Promoting Indigenous Systems of
Medicine and Healing Traditions
Poor people across the world have
developed diverse traditions of healing and
systems of medicine. Women are often the
carriers of local health traditions and also
carers of people during illness. Modern
medicine with scientific arrogance has often
135
labelled traditional knowledge as non-knowledge, and healers as quacks and witches,
causing disempowerment and loss of
heritage. There is an urgent need for
dialogue based on respect, to enable
learning, restoration and promotion of these
systems and traditions. This needs to be
accompanied by safeguarding community
and people’s rights from the avariciousness
of commercial interests and patent rights.
As part of its 5000 year old living civilisa
tion, India has evolved several indigenous
systems of medicine, such as Ayurveda (the
science of life) Siddha, Unani, and Yoga, all
with texts, which form part of the world’s
oldest written medical lltornluro. A wonlth
of local, oral traditions exist, being passed
on from generation to generation by folk
healers. Similar knowledge bases and ca
ring traditions exist world-wide. There is
minimal budgetary, legal and institutional
support for the growth and promotion of
these systems. They are scarcely involved
in health planning and programmes. Some
have been pushed into subaltern states by
the dominant modern biomedical para
digm. Recognition, legitimisation and
strengthening of these traditions will enhan
ce the contribution of people themselves
to improved health and quality of life. Sup
ported by the philosophical traditions they
represent, indigenous systems are less com
partmentalised, and deal differently with
issues such as the meaning of life, quality
of relationships, attitudes, and acceptance
of death. In the quest for health we need to
include multiple world views, multiple reali
ties, multiple voices. For this we need to
listen, to learn, and to allow a questioning
of the hegemony of modern medicine.
Fostering Community Involvement
Community involvement, a cardinal
principle of primary health care and of
community health, has been fragmented by
136
a combination of professional and commer
cial Interests (the doctor-drug producer
axis) operating through market forces. It has
been declared idealistic, non-workable and
Immeasurable by experts, who are
impatient and focussed on specifics.
The potential power of the community as
healer, as being able to hold brokenness
and restore wholeness, are human and
higher dimensions beyond market and
biomedical paradigms.
At another level, community involvement in
micro-planning, decision making and in run
ning health programmes have made possi
ble more rapid, RURlnlnnble, hnnllli uhIiir,
al low coat. I his la II ic axpei lei ica of NClOa
globally. Community participation in public
sector programmes, through elected
representatives and civil society groups,
enhance implementation, including quality.
On a larger scale, social movements of the
poor raise basic issues, which impact on
health. These include movements regar
ding livelihoods, water, and environment.
Socially conscious professionals and others
have worked on campaigns for rational
therapeutics, women’s health, and workers’
health, from which there is an emerging
health movement.
However resistance by the medical
profession to subject itself, and its technol
ogy, to social control, through local
committees, consumer and patient groups,
ethical committees and elected local bo
dies, hampers outreach, development and
access to the poor, and is one of the barriers
between people and the health services.
Bridging Implementation Gaps
All aspects of health policy in some
countries, including problem identification,
policy content, programme planning and
implementation, are influenced by dominant
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merucer
has
and
are
interests, in ways such that the needs and
interests of the powerless and poor come
last (Narayan, 1998). This is evident in the
poor implementation of tuberculosis
programmes with continuing high mortality
and poor treatment outcomes, despite
effective, low cost treatment.
' as
ess
ind
ind
High rates of child undernutrition and
anaemia; large proportion of people still
lacking access to safe water and sanitation:
high maternal, infant and child mortality: are
all witness to implementation cans in public
policy.
tin
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;si“
Political economy factors are evident in the
is,
Ds
lie
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s,
energetic promotion, on the other hand, of
population programmes, euphemistically
given new names, such as, family welfare
reproductive and child health, but still
driven by demographic determinism. These
factors are also evident in the dispro
y
portionate leverage in national policy plan
ning that donor agencies expropriate, de
spite very small proportions of actual aid.
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t.
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mcation and coordination mechanisms, the
playing fields are very uneven. Thus imple
mentation factors are complex, but need
to be given priority and close attention at
all levels, particularly locally, if better health
for the poor is to become a reality now
(Narayan. 1998).
Addressing Political Processes
and
Power
At the turn of the millennium there is a need
for explicit recognition that political
structures and processes, and issues of
power, help determine content, direction
and implementation of health policies and
programmes. Equally important is the
recognition that the medical profession itself
is a strong political player, very protective
of group interests, well organised, working
m alliance with governments, industry, and
international agencies, and often unmindful
of the real interests of the poor, despite
public statements and individual acts of
or more recently even with loans.
commitment. Professionals as a group vio
late the health rights of the citizens,
Several scholars and agencies recognise
the need to improve institutional mecha
particularly the poor, by non-implementation. non-action, apathy, non-availability,
nisms to strengthen implementation arc
reduce gaps. This includes the need for
good governance, leadership at different
levels, management, and most importantly
provision of poor quality care, corruption
and rude behaviour (Narayan, 1998)
Though occurring to different extents in
strengthened capacities and humane
attitudes and relationships, at the interface
between patients, people and providers In
volvement of different stakeholders
especially women and NGOs, with systems
of accountability and transparency, enhan
ce implementation. There is a recognition
however that the poor, preoccupied with
survival tasks, are the least organised and
articulate, with less bargaining and negoti
ating abilities. On the other hand, profes
sionals, technocrats, bureaucrats and
industry, form strong alliances. With access
to upto date information, good commu-
different parts of the world, this factor needs
recognition and redressal.
Preventing Distortions due to Privatisation
Another important issue, in the current neoliberal context, that hurts the interests of the
poor, is the promotion of privatisation in all
sectors, particularly in medical and health
oare, by powerful institutions such as the
>Vorld Bank and allied bodies. Despite cautions by WHO. these institutions used loan
-onditions to further this agenda Thus
commercial high tech, secondary and
■srttary care was introduced, opening up
137
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i
markets for multinational consumer prod
ucts, along with stagnation and reduction
in real public sector health spending. This
worsened pre-existing inequities in health.
Global policy prescriptions for contraction
of public sector expenditure, derived in part
from over-extended unsustainable health
budgets in industrialised countries,
following rising costs of medical care. Gen
eralisations to countries with different
contexts, where health budgets were far
below WHO recommended norms, makes
any contraction of health expenditure
counter productive, leaving money for
salaries but not for service or Infrastructure
maintenance. A public private mix is
advocated with a larger role for the private
sector, in the absence of evidence of
significant or sustained private sector
participation in health promotion, health
prevention, rehabilitation or public health.
There is also little evidence of greater cost
effectiveness, efficiency or quality of care
in the private medical sector, particularly in
low-income countries, where regulatory
mechanisms are least developed. These
policy changes have diminished access to
care, particularly for the poor, causing shifts
to poorer quality care in the informal sector
and in households by families, thereby
adding to the workload and anxiety,
particularly of women. The ethics of
introducing major policy changes, without
evidence or monitoring, need to be
addressed.
There is widespread concern about the
potential impact of the World Trade
Organisation (WTO) agreements on access
to health care (PHA 2000, Health Counts
2000). For instance, the TRIPS agreement
(Trade Related Aspects of Intellectual
Property Rights), through patents and
higher drug prices, prevents access by the
poor to the benefits of new science and
technology developments in the pharma
ceutical industry.
Responding to Indebtedness and Illhealth
In low income countries, in the absence of
functioning public sector health services, a
significant proportion of persons with
chronic illness or acute emergencies get
indebted while purchasing private medical
care (Narayan, 1998). In India, medical
expenditure comprises the second most
important cause of rural indebtedness.
Studies In Chinn nliow Ihnl nhinnln III hnnllli
Is a cause lor persons and lamllies being
pushed below the poverty line. Public
sector provision of medical care therefore
has a poverty alleviating effect on
households.
At a global level, NGOs, the Jubilee 2000
coalition, UNICEF and others have
documented the adverse effects of
international debt on the health of the poor.
In 40 heavily indebted poor countries, life
expectancy is 12 years lower than other
developing countries and 27 years lower
than industrialised countries (BMA, 2000).
Debt repayments surpass health
expenditures by 3-4 times in these countries.
The per capita expenditure in health in those
countries Is less than £6, while it is more
than £950 in the U.K. (ibid.).
With a total debt of $2000 billion (UNICEF,
1999) there is a net transfer of resources
from poor to industrialised countries and a
continuing of the process of impoveri
shment, which has a deep structural roots.
Besides indebtedness, conditions linked to
Structural Adjustment Programmes result in
increased unemployment, a shift to the
informal sector where there is no social se
curity, introduction of user charges, reduced
access to care, downsizing of the public
138
[
sector in health, changed nutritional status
and increased nutrition, insecurity with
withdrawal of food subsides and currency
devaluation. These changes have been
documented in Africa, Eastern Europe, Latin
America and Asia, with widening gaps be
tween and within countries. Urgent action
is required to address this issue.
CONCLUSION
Important issues concerning health of the
poor and poverty and health linkages, have
come to the global policy agenda, during
the last few decades of the millennium. They
reflect widespread concerns that we, the
human race, have not done as much as we
had hoped or expected. Valuable lessons
havd been learned, and insights gained,
during the struggle or period of trying to
reach Health for All by 2000. This know
ledge gained has been both experiential
and research based. The challenge before
us is how we integrate this knowledge, in
cluding the negatives, into positive,
affirmative action for equity in health.
Equally important is how we go about the
process, moving beyond biomedical and
market paradigms, allowing ourselves to be
led beyond barriers, especially by the
agency of the impoverished.
■
References
MMM, Medicine Meets Millennium (Pro
gramme) 2000, World Congress on Medicine
and Health, 21 July - 31 August 200, Secre
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UNICEF, 1999, Debt has a child’s face Progress of Nation, UNICEF, New York.
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?()b 208
UNDP, 2000, Human Development Report
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Narayan T, 1998, A Study of Policy Process
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"Now we are having a very difficult life,
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