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AFRO-NETS> Food for a targeter's thought (3)

  • Subject: AFRO-NETS> Food for a targeter's thought (3)
  • From: Claudio Schuftan <aviva@netnam.org.vn>
  • Date: Tue, 9 Nov 1999 00:19:43 -0500 (EST)

Food for a targeter's thought (3)

[From the Moderator: This is in fact the first part of the essay. Due
to server problems at our ISP it arrived only hours after part 2 and 3
(falsely named 'Food for a targeter's thought (1)']


An Essay on Poverty, Equity and Targeting in Health and Nutrition


Global, regional and national poverty patterns in the world are chang-
ing --mostly for the worse. The best way to improve the health and nu-
trition of the poor still is to have them move out of poverty.

In the process of pauperization, 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. Fo-
cusing 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, social inequities are always unfair.

We thus focus on equity here as reflected in the relationship between
income distribution and the health and nutritional status of the poor,
i.e., 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 disposable income
of the least privileged 20% of the population at a faster pace than
that of the upper income quintile. And this will only happen through
the combination of more income redistribution measures and government
funds being deliberately directed to achieve this goal.

The absence thus far of a serious and concerted fight for greater eq-
uity 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 tech-
nical fixes to the many problems experienced by the poor). Over the
years, neo-classical economic theories (have) served the Establishment
well in the sense that its principles deliberately exclude the redis-
tribution of resources and wealth from the rich to the poor. The influ-
ence of the same Establishment on the international organizations is
illustrated, for example, by the fact that not until the mid-1980s did
WHO recognize poverty as a distinct determinant of disease; till then,
they still talked about "tropical diseases".

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 impres-
sion that they have found a new toy: "batteries not included". Acknowl-
edging the importance of equity is simply not enough: well thought out,
concerted effective actions is what is needed.

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 epide-
miological 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) informa-
tion 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 differ-
ences in low income countries is actually not a surprise or a coinci-
dence 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 suf-
ficient step in a process. What is important is what we commit our-
selves 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 (some better, some worse) 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, inequity and violations of the Convention of the
Rights of the Child).

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 (had) 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

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.


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 democratisation
and decentralization principles central-to and inseparable-from its
philosophy. Country after country only took up PHC's technical compo-
nents 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 in-
nocence can be claimed.

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 Global-
ization is a value judgement, as is the lack of confidence in the pub-
lic sector approach to PHC. It all depends on how decisively and quick
a shift to greater control by the beneficiaries occurs at the grass-
roots. Both in health and in nutrition, the emphasis now rightly cen-
ters more and more on tackling ill-health and malnutrition as viola-
tions of Human Rights --with all the political connotations such an ap-
proach brings about. That is surely a step in the right direction.


Responses of the kind proposed in the Adjustment with a Human Face ap-
proach are clearly neither sufficient nor acceptable any longer, par-
ticularly since 1997, given the devastating multi-centric economic cri-
ses the world faced. Safety nets leak and have just not worked for the
poorest. The poverty and equity (as well as international debt) issues
have to be tackled frontally --, once and for all and 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 develop-
ment professionals plus representatives of the civil society both in-
ternationally and in each individual country. Are these two global in-
stitutions willing to go along with this? That is the 'sixty four thou-
sand 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 face-to-face and electronic meetings in this bud-
ding movement in the WB and elsewhere is not enough. The poor need ac-
tion. 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.


Amartya Sen, our recent Nobel laureate, has been credited for his
ground-breaking re-definition of poverty, actually basing it on the ca-
pacity 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.

So to get the process towards equity rolling, we (professionals) have
to move away from defining who the poor population groups are. Espe-
cially inappropriate are blanket arbitrary (absolute poverty) income
cut-off points. Communities themselves are the best qualified to iden-
tify the poor amongst them in each locality (thus judging relative pov-
erty). 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 mortal-
ity of the lowest income or expenditure quintile in low income socie-
ties is perhaps not the best indicator or predictor of inequity, as
proposed in WHO's 1986 Health Assembly. As said earlier, stunting
(deficits in height for age) in under threes is a better, more sensi-
tive 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 expec-
tancies 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.

Claudio Schuftan
Hanoi, Vietnam

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