Poverty, equity and social justice
Equity and health for all
Equity, structural adjustment and safety nets for the poor
Who are the poor and how do we find them?
Equity and the public/private allocation of resources
Avenues and dead-end streets to equity
Equity and targetry
Equity and participation
Equity and prepayment schemes
Equity and social security
Where to go from here?
CLAUDIO SCHUFTAN
schuftan@gmail.com
Poverty, equity and social justice:
Global, regional and national poverty patterns in the world are changing -mostly for the worse. The best way to improve the health and nutrition of the poor still is to have them move out of poverty.
In the process, health and nutrition are also turning to the worse. In this context, what is most often ignored these days is that focusing on sustainable poverty alleviation is inseparable from bringing about greater equity. A focus on both tasks is necessary to achieve the indispensable reduction in the existing rich-poor gap. Focusing on poverty alleviation alone can end up as charity in disguise. Focusing on equity is a step towards social justice.
Equity and social justice in health and nutrition are one and the same thing: in health and nutrition, an inequality is always unfair. And this includes gender, racial, ethnic, cultural, socioeconomic and other inequalities: when they exist, they are all related -and are all rooted in different manifestations of the same discrimination pattern.
Equity focuses on the relationship between income distribution and the health and nutrition of the poor, and/or on the rich-poor differences in health and nutritional status. For equity to be achieved, economic growth in the development process needs to be deliberately geared towards the needs of the poor. It is this latter fact that explains why we can no longer ignore our obligation to search for options outside the health and nutrition sectors in our search for greater equity in health and nutrition.
As a prerequisite to work on equity, we therefore have to accept that greater equity will only be achieved by raising the income of the least privileged 20% of the population at a faster pace than that of the upper income quintile. What it is all about is to work on ways that will redistribute the wealth pie (which is still scandalously concentrating even more wealth in the hands of the richest).
The absence thus far of a serious and concerted fight for greater equity in health and nutrition is not a historical accident. Ignoring ‘equity-as-a-priority-condition-to-aim-for or aspire-to’ has suited the pro-status-quo Establishment. (In the process they have convinced all of us health and nutrition professionals to keep trying ever new technical fixes to the many problems experienced by the poor).
The (re)emerging concern for poverty alleviation and equity in health and nutrition we now see is not really new. Perhaps for some it is. But the centrality of poverty and equity issues as the main basic causes to be tackled to overcome ill-health and malnutrition has been kept up by a minority of concerned and politically committed colleagues all along.
In the case of those who are ‘re-discovering’ the importance of equity in the battle against ill-health and malnutrition, one gets the impression that ‘the child has found a new toy and is excited about it; but the toy is not new; it is just that few wanted to play with it before. Now he has it, but the batteries to run it are not included, so the child still cannot run it’.
Many of these well-intentioned re-discoverers of equity justify their late uptake of poverty and equity as priorities beyond mere lip service to the dearth of basic information so far that shows convincing epidemiological morbi-mortality differences by income quintiles. But there is a difference between acknowledging shortcomings in the data base and having a blind eye for the existing (even if sometimes scanty) information on this matter. There is an element of selective blindness here that hardly justifies having been kept in the dark (or having chosen to stay in the dark). This is part of the so-called ‘exclusion fallacy’ in which what we choose not to discuss is assumed to have no bearing on the issue…
The current dearth of epidemiologic data on rich-poor health differences is actually not a surprise or a coincidence either; rather, we have to accept it as a deliberate omission. Furthermore, collecting and making such equity-relevant data available is no solution in and by itself either; it is a necessary, but not sufficient step in a process. What is important is what we commit ourselves to do with those data, how we use them proactively to correct inequities, and starting when.
So many of the health surveys we design (less so for nutrition surveys) fail to collect good information on household income or expenditures. We thus often fall prey to use education, occupation and/or urban/rural residence as proxies to rank the populations under study. Interestingly enough, the opposite is also true, i.e. cases in which researchers use health or nutrition indicators as a proxy for economic status. (Stunting may actually be a quite excellent indicator of poverty).
On the other hand, it is misleading to say that until now there has been ‘a lack of a strategic vision to tackle poverty and equity in health and nutrition’. The literature has never stopped giving us those insights that have enough potential to guide more equity-oriented strategies. But it seems too many of our mainstream professionals have chosen to ignore such advice -the exclusion fallacy at work here again.
So now, there seems to be a new opportunity -even for the Bretton Woods institutions… Powerful alternative approaches are being brought to the fore that can be put in place to start making a difference on equity. There is just a lack of consensus so far on where to go from here, as well as die-hard conceptual differences that still need to be overcome. Differences in perspectives are still significant, no doubt, both on conceptual and practical matters. Most of these differences are ideological; other are related to old concepts in the current Western-led development paradigm that is crumbling, but not without a last ditch struggle. Therefore, these differences are not easy to overcome. But we need to tackle this Gordian knot (and provide the batteries for the toy) if we want to start making a difference. In our case, we need to adopt a more suitable paradigm for sustainable improvements in health and nutrition as we approach the dawn of the 21st century.
Unfortunately, the renewed interest in poverty alleviation and equity in our international health and nutrition community still is top-down; it ignores the contributions the poor themselves need to make to the debate. One can see here a set-up for yet another failure.
Equity and health for all:
A sizeable interest in poverty and equity issues already existed in the mid 70s. At that time, Basic Human Needs were emphasized; that interest and emphasis faded with no glory. Then came Alma Ata. As defined there, PHC indeed addressed poverty and equity issues. But PHC, as applied in most of the world, ended up never addressing the basic democratization and decentralization principles central-to and inseparable-from its philosophy. Country after country only took up PHC’s technical components and, worse, even those were later trimmed to yield the well-known selective PHC approaches. What role the UN agencies and the Bretton Woods institutions played in this is debatable, but -for sure- no innocence can be claimed. It is well known, for instance, that in the 80s the World Bank took over from WHO giving direction to quite a few of the health policy orientations during WHO’s ‘period of low morale’. (This situation peaked with the WB’s 1993 World Development Report devoted to health that launched the controversial DALYs).
The bottom line is that, despite its shortcomings, PHC still deserves our support today even after not having achieved Health For All 2000. The question is what type of PHC we should support more aggressively now. Going back to Alma Ata is a good start. Then, decisively fixing PHC’s well-known deficiencies (mostly the non-technical ones) can be the basis to get going -the sooner the better. We need to make PHC what it should have been from the outset, namely, a public sector driven vehicle fostering true equity in health. Privatization is simply never going to lead us to such a path…
The claim that Health for All is not attainable in the era of globalization is a value judgement, as is the lack of confidence in the state sector approach to PHC. It all depends on how decisively and quick the shift to greater control by the beneficiaries occurs at the grassroots. The emphasis now rightly centers more on Human Rights and their political underpinnings. That is the way forward.
Equity, structural adjustment and safety nets for the poor:
Responses of the kind proposed in the Adjustment with a Human Face approach are clearly neither sufficient nor acceptable any longer, particularly now, given the growing multi-centric economic crises the world is facing. Safety nets leak and have just not worked for the poorest. The poverty and equity issues have to, once and for all, be tackled frontally -now.
What this means for the Bretton Woods institutions is that the WB and the IMF need to overhaul their entire Structural Adjustment packages engaging the participation of the international community of development professionals plus representatives of the civil society in each individual country. Are these two global institutions willing to go along with this? That is the ‘sixty four thousand dollar question’. Initial rifts between both institutions that surfaced during their 1998 annual meeting in Washington allow for a guarded optimism on possible changing winds within the WB.
But drawing renewed attention to poverty AND equity at high level brown-bag lunches and meetings in this budding movement in the WB and elsewhere is not enough. The poor need action. They need to begin seeing deeds. Bringing equity to the center of our attention without incorporating representatives of the poor into our deliberations, as said, assures yet another fiasco, one we can no longer afford.
Who are the poor and how do we find them?:
Amartya Sen, our recent Nobel laureate, is credited for his ground-breaking re-definition of poverty, actually basing it on the capacity of the poor to improve their condition (which is mostly a local determinant). This seems much more proactive an approach to reaching equity and to bridging the rich-poor gap than sticking to old, more passive and pejorative definitions of poverty.
But to get the process towards equity rolling, we (professionals) have to move away from defining who the poor population groups are. Especially inappropriate are blanket arbitrary income cut-off points. Communities themselves are the best qualified to identify the poor amongst them in each locality. Flexibilities of this kind need to be encouraged in national and sub-national programs. International agencies ought to insist on it.
On a more technical note, there is growing evidence that infant mortality of the lowest income or expenditure quintile in low income societies is perhaps not the best indicator of inequity. As said earlier, stunting (deficits in height for age) in under threes is a better, more sensitive indicator, mainly because it is an outcome indicator that reflects the many chronic deprivations that accompany the poor from birth (that not necessarily result in death). (See Nutrition and Poverty papers from the ACC/SCN 24th Session Symposium, Kathmandu, March 1997, ACC/SCN Nutrition Policy Paper No.16, Nov.1997) We should here simply take note that the rich-poor gap in stunting seems to again be widening worldwide following a period of narrowing (and the same is true for life expectancies in low income countries). Many of us are thus echoing the calls for using stunting trends as one of the good indicators of trends in overall equity in society.
Equity and the public/private allocation of resources:
At the national level, resources allocation to and within health and nutrition remains skewed and inequitable. Not enough pressures have been exerted yet to attain more equitable distribution patterns. For example, pressures to have governments allocate higher percentages of the national budget to the sector and pressures for a more equitable distribution of funds among provinces have, for the most part, not been exerted. Similarly, the distribution of national poverty indicators and the provinces’ percentages of minority/remote populations are not yet sufficiently considered when the ‘pie is cut’ every year. Covering their needs is more expensive, but indispensable.
In the provision of services, government-directed systems have different impacts on equity than mixed public-private systems. In the latter system, the rich tend to crowd out the poor at several levels of consultation, especially hospitals. Moreover, current government health services expenditures tend, in many countries and in many different ways, to benefit the richer more than the poor. Private health care, on the other hand, often is of poorer quality than government services especially in places where it is just emerging. Country by country analyses of these issues need to be carried out to assess their impact on actual equity and to find relevant and balanced local solutions that preempt most loopholes.
Avenues and dead-end streets to equity:
Despite the fact that many policy-makers among us say they agree with most of the views expressed above, we nevertheless see that -in the name of greater equity- many currently proposed approaches to resolve the problems of health and nutrition still only favor and select actions covering, for the most part, four strategies: (*)
– targeting of services (the No. 1 choice),
– participatory approaches (a distant second),
– risk pooling (insurance schemes), and
– expansion of social security schemes linked to health/nutrition benefits.
These four strategic approaches -purportedly leading to equity- depart from the question: If not PHC, then what?
For the reasons given earlier, I contend that, to start with, this is the wrong question. Many of us think we do not need to develop alternative approaches to PHC. Rather, what is needed is to mobilize a strong political popular support for a comprehensive truly equity-oriented health and nutrition policy, using an improved PHC approach that, at its core, resurrects the Alma Ata spirit; other proven elements can be added as called for. (See David Werner’s “Health and Equity: Need for a People’s Perspective in the Quest for World health”, presented at the 20th anniversary celebration of the Alma Ata declaration, Almaty, Kazakhstan, 27-29 November, 1988).
We need to decisively open up PHC to incorporate more of the (for too long disregarded) locally arrived at solutions. This requires demonstrating a willingness (and showing the boldness) to ‘risk’ a bottom-centered trial and error period led by repeated people’s participatory Assessment, Analysis and Action cycles that blend both bottom-up and top-down approaches.
Equity and targetry: (**)
Many of us also think it is a fallacy to propose targeting as an alternative to PHC (if and when applied in its full Alma Ata spirit). In a way, individual targeting is a new variant of a selective PHC approach: “Go for the worst cases, fix them, and improve the statistics”. But where are the sustainable changes to avoid the recurrence of the same problems being addressed? Unfortunately, individual targeting is seen as central among the alternatives being proposed by the World Bank and other major funding agencies (together with geographical and other types of targeting).
In an era of fee for service delivery systems promoted by free-market proponents, one of the key issues for individual targeting to keep a semblance of equity seems to be the exemption from user fees for the poor. Unfortunately, these waiver schemes, with all the variations of it we have seen worldwide, have proven to be mostly catastrophes. On top of this, from the way they look, these fee exemption schemes are often implemented insincerely, only as a political maneuver to make user fees more palatable to the population when first introduced.
In short, to many of us, individual targeting cannot be made to work equitably and effectively, and weeding-out and providing the needed services to the target individuals or groups is definitely a costly alternative for what one can potentially get…
Geographical targeting has probably more potential, but more so in the realm of a revised PHC approach. Nevertheless, one has to keep in mind that poor areas have little political clout to fight for their share and are also usually administratively weak to implement the needed changes. Even at somewhat higher costs, this type of zeroing in on the poorest makes sense in terms of equity.
Starting with targeting interventions as the central thrust to achieve equity (no matter how carefully designed) thus seems the wrong approach to put most of our efforts in; it is a dangerous path to follow; it pursues what rather is a ‘mirage of equity’ that basically leaves the perennial determinants of the rich-poor gap untouched.
What we desperately need at this time (to satisfy remaining skeptics -if that is worth the time and the money needed…) is to compare the effects on long-term equity and health/nutrition indicators of selected individual targeting interventions and of a host of already tried direct poverty alleviation measures. The data for this may already be there or may be still missing, I acknowledge my ignorance.
Equity and participation:
On the other end of the spectrum, and for quite some time, a few genuine participatory approaches have coexisted with mainstream more top-down health/nutrition approaches. The former have often faced an uphill battle with the respective Establishments to gain recognition. Nevertheless, enough (small) success stories have been reported for planners, as well as local communities, to draw valuable experiences from. Beware though that the sector is full of what in reality are pseudo-participatory approaches since almost no project in the 1990’s dares to lack a ‘community participation’ component. In the latter, local communities are called-upon to give limited inputs, but are not on the driver’s seat when it comes to steer project activities. One can genuinely be sceptical when one sees calls for participatory approaches in projects that have not taken the poverty reduction and the promotion of greater equity as their central thrust. Most often, communities are not being empowered to implement measures that directly aim at having them gain growing control over the assets and resources they need to improve their own lives.
Equity and prepayment schemes:
Let us now turn to health insurance schemes (which cover almost nothing in the realm of nutrition) So far, planners have brought these schemes to the fore more (or only) as a priority health care financing mechanism rather than as a measure to further equity. Health insurance schemes -especially when compulsory- raise funds for the struggling public health sector (far more than fee for service schemes) and complement the governments’ dwindling investments in the health sector. For now, these insurance schemes remain a direct (health) tax that benefits mostly the (often coaxed) non-poor.
Therefore, beware: health insurance schemes do spread risks, but -in and by themselves- do not redress rich-poor differences! They do not necessarily improve the quality of care for the insured either. These schemes may actually worsen the rich-poor differences: e.g. hospitals give preference to hospitalize insured patients to the disadvantage of the uninsured poor.
It is time now for insurance schemes to look for avenues to address equity issues… and this is not the reason the WB is choosing this approach as one of its four priority strategies.
Equity and social security:
The expansion of social security schemes linked to health and nutrition benefits is, in a way, a variant of the health insurance approach. It importantly calls on the experience of Latinamerican countries in this domain. It is an approach for salaried workers covered under the social security system in which they, as well as the employers pay for social benefits, including health benefits. The scheme therefore also leaves the peasantry, the workers in the informal sector and the indigent (i.e. most of the poor) largely beyond reach. Ergo, this strategy is also, at best, equity neutral, but most probably equity detrimental.
Where to go from here?
Because overall poverty reduction is a theme getting growing attention these days (the upcoming World Development Report 2001 will again be devoted to poverty), health and nutrition professionals have a golden opportunity to work harder to influence overall development strategies towards equity in health and nutrition. We should not ‘leave it up to the Joneses’ again and miss this unique opportunity. The sense of urgency is heightened when we accept the fact that the health/nutrition sector cannot, by its technical actions alone, make significant improvements in the health/nutrition conditions of the poor.
Breaking down health and nutrition data by income quintiles, as proposed by the WB, is a welcome first move to consolidate a credible international database that can be used to track equity issues in health and nutrition. Results from the analysis of these data should be published annually in a publication of the type and stature of UNICEF’s “The Progress of Nations” or UNDP’s “World Development Report” where countries are ranked according to their respective performance. The publication would further analyze existing gaps and targets would be set for improvements for the following year.
But actually using these data to tackle the inequities at national, sub-national and especially the local level is where the real challenge lies. Donor agencies will have to more forcefully advocate for equity-promoting, participatory, bottom-centered interventions, as well as being more responsive to low income countries’ government-initiated requests for funding to prepare and execute policies specifically addressing the central equity issue.
Governments and donors will have to enter into binding commitments (with signed memoranda of understanding?) to move in the direction of poverty alleviation and greater equity including the close monitoring of progress. These binding commitments will be needed as a precondition for continued support. Funds would then be released in tranches based on the achievement of negotiated verifiable indicators of progress along the line of project implementation. A donor-NGO/civil society link and funding window should be developed concomitantly along the same lines. In the case of non-responsive or non-performing governments, donor funding earmarked for use by the latter should be progressively reallocated to the NGO/civil society sector. Non-performing NGOs should be dropped under the same guise.
All this may only add up to a start -from the top at that. But it is a start in the right direction. The road ahead will, for sure, require our greatest boldness ever.
For a change, let the more creative inputs on ways out of the dead-end street of non-inequity-redressing individual targeting come from the more directly affected themselves. It will be a big leap forward if we devote most of our energies to facilitate just that process.
Acknowledgements:
I am grateful to Mr Goran Dahlgren in Hanoi for the detailed comments he gave me on the draft of this essay. Many of his suggested improvements and ideas have been incorporated into the text.
(*): Some of the ideas here expressed are reactions of the author prompted by reading Davidson Gwatkin’s recent draft paper entitled: Poverty, Equity and Health in the Developing World: An Overview, Initial Discussion Draft, World Bank, August, 1998.
(**): Term borrowed from Simon Maxwell.
Claudio Schuftan
Saigon, Vietnam.