AFRO-NETS> Food for a poor thought on health and poverty

[Claudio Schuftan <aviva@netnam.vn>]

Food for a poor thought on health and poverty
---------------------------------------------


HEALTH A PRECIOUS ASSET(*), BUT NOT "A NEW AND POTENTIALLY POWERFUL 
EXIT ROUTE FROM POVERTY"(**)


WHO's proposal for a Copenhagen Plus Five follow-up is indeed an un-
even document(*). It has a powerful and quite progressive analysis of 
"the health revolution that has left out a billion people" and "the 
health services in crisis". But it falls short in suggesting remedies 
that could address what it criticizes. Moreover, some of the proposed 
areas of action clearly contradict the analysis.

Its merits notwithstanding, I will here only focus on what I think 
are the negative and contradictory aspects of the integral health 
components of poverty reduction WHO proposes for the follow-up of Co-
penhagen+5.

WHO's proposals for Strengthening Global Policy for Social Develop-
ment are left very general and vague: They call for turning global-
ization to the full advantage of poor and marginalized populations, 
but they do not tell us how. They call for designing responses to the 
negative effects of globalization on health equity, but they do not 
tell us how. They pledge to help making trade work to improve health, 
but they do not tell us how. They call for developing of health pro-
tection norms to guide the business sector when they have criticized 
the capacity of this sector in the analysis earlier on. They further 
call for building a global knowledge base on social development with 
regard to health, but they do not tell us what good this will do. 
(p.16)

When it comes to proposing Actions to Integrate Health Dimensions 
into Social and Economic Policy, the introduction of health impact 
assessment analysis tools is portrayed as being new (when they are 
not) and does not zero-in on the need for a differential impact as-
sessment that singles out the inequities suffered by the poor and 
marginalized. WHO then goes on to offer guidance to countries on the 
specific mix of investments they need across sectors to ensure pov-
erty reduction when the document has said earlier (on p.14) a) that 
market interventions in health care are anti-poor (as well as likely 
to deepen current inequities), and b) that the private sector gener-
ally does not provide quality health care at reasonable cost (public 
intervention is necessary to achieve universal access, they correctly 
add). Promoting social insurance (formal and informal) is rightly 
highlighted as a necessary measure, but no elaboration follows this 
statement. Finally here, WHO proposes to provide evidence for elabo-
rating technical options as the basis for more informed macroeconomic 
decision-making; one is, of course, left wondering how much technical 
options - in the absence of political options - will achieve. (pp.17, 
18)

Then, under Developing Health Systems which Target Health Problems 
Affecting Poor and Vulnerable Populations, the document again calls 
for marshalling the efforts of private providers to contribute to im-
proving the health of the poor; the silver bullet on how to exactly 
do this is assumed to be self-explanatory. We are then promised that 
the World Health Report 2000 (which has created an uproar) will ad-
dress in depth what policy makers and program managers can do to cre-
ate more equitable health systems. Now, did it really? A great deal 
of emphasis is laid on championing substantial reductions in the mis-
ery caused by major diseases affecting the poor calling these (mostly 
vertical) programs "pro-poor"; but WHO fails to say that this is 
strictly palliative and that none of this attacks the roots of pov-
erty itself thus preventing that more poor are affected equally later 
on. The major factor leading to poverty simply is not illness per-se. 
Moreover, targeting the poor mostly victimizes them as if they were 
responsible of their fate, but that is not said. In our daily work, 
we are told, the tools we use to control health problems are failing 
due to "market failures", not even considering that they may be the 
wrong tools being applied on the wrong end of the problems. (pp.19, 
20)

Most of my problems with WHO's position on Copenhagen+5 come from the 
last page of the document. It calls for "Promoting a Responsible 
Health Stewardship" -- as if we had a shortage of jargon around. As 
it turns out, this is to mean ensuring responsible management (or 
harmonizing functions and overseeing all components of the health 
system, as is said). This, as if better management alone would be 
able to redress the situation in which the health revolution left out 
a billion people. Then, towards the end, the contradictions simply 
pile up: 
- Ministries of health need to make efforts to engage the resources 
of the private sector (the provisions of the private sector are espe-
cially important for the poor...!; ...financial incentives and con-
tracts are to be given to the private sector, at the same time assur-
ing that private insurance and the pharmaceutical houses contribute 
to the overall goals of the health system). 

- Ministries are to shift from 'rowing to steering', i.e. from di-
rectly providing to overseeing multiple actors and holding them ac-
countable through stronger monitoring (but no hint is given on how 
and if such a monitoring alone will change things for the poor for 
the better).(p.21)

If this all does not sound like WB language then I do not know what 
will. (Actually, on p.15, the document calls for WHO to strike 
partnerships: it singles out close collaboration with the WB and the 
IMF leaving other agencies unmentioned).

To me, it seems that this WHO proposal was written by different teams 
and then was hastily put together without checking for consistency. I 
stand to be proven wrong, but until then, somebody better fix this 
conundrum.

Claudio Schuftan
Hanoi, Vietnam
mailto:aviva@netnam.vn

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