Communities –and not academics setting cut-off points– are the best qualified to identify the poor among themselves thus judging relative poverty.
1. In our work in health, we see equality and social justice as one and the same thing. The point reiterated here is that we can no longer ignore our obligation to search for greater equality of results in health. As a matter of fact, there is a disturbing absence of a serious struggle for greater equality of results in all development-related professions… and that is not a historical accident.
2. The current dearth of epidemiological data on rich-poor health differentials in both rich and poor countries is actually not a surprise or a coincidence either: it has been a quite deliberate omission. In addition to generating more data broken down by income quintile, by gender, by ethnic group, by migration status…, we need to commit ourselves, with no further delay, to do something with the data so disaggregated in a drive to correct existing inequalities –and then to use the data to track improvements (or not) in results related to human rights (HR) conditions.
3. For a while now, there has been a renewed interest in disparity reduction and equality issues among our peers, but the same is still mostly top-down; it seldom incorporates the contributions of those-that-happen-to-be-poor themselves. One can see a set-up for yet another failure here…
4. In the case of health, we thus need to make primary health care (PHC) what it should have been from the outset –a public sector-driven vehicle very centrally fostering equality of access and of results in health. (Privatization will never lead us to such a path!). Following the above argument, all will depend on how decisively and quick a shift to greater control by ‘beneficiaries-made-active-claim-holders’ occurs.
5. Many currently proposed approaches to resolve health problems –including those of the World Bank and other donors– focus on ‘targeting’ health interventions to the poor (part of the so-called ‘pro-poor interventions’). From the HR perspective, it is a total fallacy to propose targeting as an alternative to comprehensive PHC, as the latter was originally conceived in Alma Ata. Individual targeting is equivalent to the discredited ‘Selective PHC’ approach of the 1980s, i.e., “Go for the worst cases, fix them, and improve the statistics”.*
*: From a HR perspective, the question we have to ask about targeting is: Where, through targeted interventions, are the needed sustainable, structural changes being made? (Those changes that will replace the system that reproduces poverty and ill-being generation-after-generation, i.e., changes that will avoid the recurrence of the same problems that make targeting purportedly necessary to begin with?).
6. Let us be categorical: Targeting keeps a semblance of working towards equality. Targeting can and does stigmatize the poor creating second-class citizen that can be (and are) manipulated.**
**: We are reminded here that fee-for-service waiver schemes for the poor tried in many places have proven mostly catastrophic.
7. Individual targeting is not a substitute for a more redistributive public policy! Geographic targeting has probably more potential (i.e., concentrating interventions in the poorest districts –but with both technical and structural interventions that address the social determinants of health).
8. Starting with targeting interventions as the central thrust to achieve equality of results goes against the grain of the HR-based approach. It pursues what is rather a ‘mirage of equality’. It tacitly blames the most vulnerable for being-where-they-are and tends them a rescuing hand (or throws them a charitable bread crumb…). [Remember: In HR work, we move the focus from charity to dignity. (Shula Koenig)].
9. Targeting initiatives in health deserves to die a quiet (or not so quiet) death.
10. The remedy?: Let inputs on alternative, truly equality-fostering schemes in health come from the more directly affected themselves; let them rise to the challenge. Devoting our energies to facilitate such a process will be a big leap forward for all.
Claudio Schuftan, Ho Chi Minh City
cschuftan@phmovement.org