Editorial

Are institutions that tap poor people’s desire for credit, shrinking Third World states’ already beleaguered welfare policies? The role of microfinance in poverty reduction, reducing risk environments for HIV and promoting private health insurance has attracted high profile interest since Muhammad Yunus won the Nobel Peace Prize last December.

Yunus’s Grameen Bank battled backward Bangladeshi patriarchal and religious attitudes to extend credit to millions of people. Poor women were typically arranged in groups of five: two got the first tranche of credit, leaving the other three as ‘chasers’ to pressure repayment, so they could in turn get the next loans. But a decade ago (at a time of lower foundation subsidies, new competitors, adverse weather conditions and a backlash by borrowers who used collective power of nonpayment), Grameen imposed dramatic price increases on loan repayments and resorted to extreme pressure techniques, including removing tin roofs from delinquent women’s houses. This reduced Grameen Bank’s main philosophical position - ‘We consider credit as a human right’ - to merely an argument for access, not affordability. This distinguishes Yunus from all rights-based social movements demanding ‘rights’ to free lifeline access to healthcare, AIDS medicines, education, housing, land, water, electricity, etc.

According to Munir Quddus, chair of the Department of Economics and Finance, University of Southern Indiana, the model needs more investigation: ‘The very nature of setting up groups leaves out the very poor who would be perceived by fellow members to have no ability to generate income and therefore high risk … microcredit simply deepens the exploitation of the women since the rates of interest charged by the bank in real [after inflation] terms are quite high; consequently, credit often worsens the debt situation and gives the husbands even more leverage.’

Evidence on South Asian microcredit and major credit programs suggest that credit does not necessarily have a positive impact on social relations. Many loans targeted at women are appropriated by male family members, leaving women as buffers between their spouses and lending institutions, with often stressful and violent results. Even where women’s incomes have increased, research found women’s work and debt loads also increased. Women’s access to credit does not guarantee improved confidence, mobility, control over assets, or freedom from violence. Therefore, microcredit must be interrogated to determine if it is really about poor people gaining control, or if it leaves structural and often global causes of poverty unaddressed.

For example, in 1998, when an emerging market crisis led to rising interest rates across the Third World, South African microlenders and borrowers were driven into bankruptcy by a 7% increase imposed over two weeks as the local currency crashed. In Zimbabwe, a 1980s US$66 million flood of World Bank financing revitalised the rural microfinance sector (initiated under 1940s Rhodesian rule) and reached 94,000 households. But within a decade, the peasant default rate was 80% - with repayment affordability being a huge factor (a typical lender’s overhead and collection costs on a small loan were 15-22% (including incorporation of a 4% default rate)). Michael Drinkwater’s (1991) detailed study of central Zimbabwe showed peasant farmers faced serious difficulties in servicing loans of just a few hundred US dollars, since average net crop profit was just $0.15/hour of labour, according to a 1989 Agriculture Ministry survey. This was compounded by ‘an overzealous launching of a group credit scheme’ and the ‘doubtful viability of high cost fertiliser packages’, inappropriate for the erratic climate. ‘The increase in credit use means farmers have to market more to stay solvent ... At the household level it is commonly debts not profits that are on the rise.’

This raises the question: ‘Is credit the most useful input for African peasants’ economic and social wellbeing, especially women?’ According to Mohindra and Haddad (2005), women’s health capabilities (opportunities to achieve good health) and health functionings (e.g. being healthy), ‘can be expanded via key determinants of population health, such as access to resources and autonomy’, with microcredit as a primary tool. But is microcredit really a tool for expanding access to health inputs when the structural disempowerment and malfunctioning markets that bedevil credit systems are added to the overall retreat of the Third World welfare state?

The question is important as Grameen-style microcredit is increasingly linked to health services ranging from education to insurance, including: the Niger CARE ‘Microcredit and Health Education for HIV/AIDS-Affected Women and Children in the Valley of the Widows’; the Philippine NGO Innovations for Poverty Action and the Green Bank marketing of health insurance and preventative care through 2000 microentrepreneurs; or
the International Medical Corps microcredit project to support local health programs in Eritrea. The Microcredit Campaign Summit pointed to many new opportunities to substitute microcredit for state or donor assistance in reproductive health education. But such schemes need to be questioned on: whether they deliver on resources and autonomy, how they change local power relations; and their record on arrears, social conflict and defaults.

Few rigorous studies document the relationships between financial vulnerability and health burdens. A study of a Dominican microcredit program, which made small loans to individuals to start or expand small businesses, included three communities: one with health promotion alone; one with microcredit alone; and one with both. The community with parallel microcredit and health promotion programs had the largest changes for ten of eleven health indicators. However, the study also traced health gains to improved ability to purchase commercial water supplies, making a link between microcredit and the demand on poor people to pay for commercial and privatised water. As the UNDP Human Development Report (2006) noted, microcredit is explicitly used to promote the market in essential services and enable poor households to meet the financing requirements.

While not denying the prospect that some microcredit schemes are worthy and effective, the criticisms raised offer warning. Claims made about microcredit as an overarching strategy to end poverty, change power relations, attack structures of inequality or improve vulnerable population’s health education should be treated with caution. Certainly, microcredit cannot stand in for decent social policy when it acts as a safety net, co-existing with and not transforming entrenched structures that generate poverty . In the worst case, microcredit can become an ideology explicitly hostile to state support for healthcare.

‘I believe that “government”, as we know it today, should pull out of most things except for law enforcement and justice, national defense and foreign policy, and let the private sector, a “Grameenized private sector”, a social-consciousness-driven private sector, take over their other functions.’

To illustrate the dangers ahead, those were words uttered in the 1998 autobiography of Nobel Peace Prize winner Yunus.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat at TARSC, email admin@equinetafrica.org. A more detailed analysis of the issues raised in this editorial can be found in Microcredit Evangelism, Health and Social Policy by Patrick Bond, Forthcoming in the International Journal of Health Services, June 2007.

There have been dramatic changes to municipal services such as water and electricity since the end of apartheid in South Africa, with considerable research having gone into the impacts of commercialisation and cost recovery on low-income households. The research has revealed a complex and often negative relationship between the marketisation of these services and access and affordability for the poor. It has also been shown to have direct and very negative public health implications, most acutely in low-income township and rural areas.

Less obvious, and much less researched, have been the impacts of changes in service delivery on the mental health of low-income residents and household members. The fact that there is a relationship between poor mental health and poverty in general has now been well established. Common mental disorders (notably, anxiety and depression), while once thought to be the preserve of the rich who could afford the ‘luxury’ of worrying about emotional issues, have in fact been shown to have higher prevalence in low-income households. It has also been suggested that there is a cycle of vulnerability between poverty and marginalization, physical ill health, emotional distress, and mental disorder.

What, then, might be the links between poverty, mental health and the shift towards market-oriented reforms in basic services? A preliminary detailed ethnographic study of ten low-income families coping with a serious mental disorder (schizophrenia) in Cape Town pointed to several problems including:
• Health and safety problems. Household members have difficulties in ensuring appropriate use of medication (due to lack of water), practicing adequate hygiene, growing their own food, and with general comfort (such as being warm and dry). There are also concerns about being forced to use open fires, candles and paraffin stoves for cooking and warmth, leading to additional health and safety worries such as poisoning, fires, and respiratory infections.
• Time and energy. Considerable time and energy are spent searching for alternative sources of water and electricity and having to live with limited supplies of both.
• Social tensions. Respondents expressed concern with having to borrow money or water from neighbours and family members, leading to additional stresses in the lives of
household members and often to tensions within families and neighbourhoods, exacerbating the stigmas typically attached to mental disorders.
• Social activities. Reducing service consumption has implications for people’s social lives and household entertainment. Most of the households interviewed owned a television or radio, for example, but were reluctant to use them due to electricity costs. One family member reported being bored at home and therefore spending time with peers who encouraged him to use drugs. This has important implications for health, as co-morbid substance abuse has been shown to play a role in relapse of schizophrenia as well as being implicated in the onset of psychosis.
• Relapse. The stress of not being able to afford adequate services, or having these services cut off or restricted, would appear to add considerable stress to the person with the mental disorder, possibly contributing to a worsening of the disorder and/or a relapse.
• Impact on care-giving environment. Inadequate services would appear to increase levels of stress and burden for the caregiver(s), with implications for their own mental health. This then impacts on the family member with the mental disorder as well as the household as a whole, as the caregiver’s ability to care for the family may be compromised. Women appear to be the most affected by this as the primary caregivers.

Households experienced considerable financial hardship as a result of cost recovery strategies on basic services, with 29% of household income being spent on water and electricity on average, and arrears on water and electricity bills as high as R18 200. This situation caused anxiety and added considerably to overall family stress.

While households used a range of strategies to minimise water usage, the need to save water was a further source of anxiety and conflict. Similarly, concerns were raised about electricity usage and cut-offs, with disability grants being used to pay for fuel and basic services in many households.

While direct links between experiences of service delivery difficulties and the onset or relapse of mental disorder cannot be drawn, but it is clear that uncertainty about services in the context of poverty add to overall stress levels. Much remains to be done in terms of realising the rights of people with mental disorders (and their families) in South Africa. Without considering the broader context of poverty and service delivery it will not be possible for them to adequately improve their lives.

Editors comment: This issue of the newsletter presents material on mental health and equity, and we note the limited publication found in this area. EQUINET invites further contributions on mental health in Africa, and particularly in relation to equity issues. Please send contributions, feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org. Further information on issues raided in the briefing or the Municipal Services Project see http://www.queensu.ca/msp/ Greg Ruiters, Institute for Social and Economic Research, Rhodes University Grahamstown.

Recent media attention in South Africa has drawn attention to an outbreak of Extreme Drug Resistant (XDR) TB and the need to contain infectious diseases such as XDR TB by extraordinary methods such as quarantine. Such measures, typical of the public health approach to community health problems, involve the limitation of individual rights in the interests of the public good. In this case, the need to contain a costly, highly dangerous and virtually untreatable form of TB by forcibly quarantining patients with this form of TB, were said to outweigh the rights of the patient to autonomy and freedom of movement. Rightly, discussions in South Africa focused on whether the restrictions of the rights of the individual in the interests of the greater good could be justified.

At one level, this is an important debate because it is typical of many other public health conflicts (e.g. in relation to HIV or claims on scarce resources), where individual rights run into conflict with interests that represent a collective or social benefit. Resolving such conflicts in ways that retain respect for human rights whilst advancing public health is important for public health planners, and methods to do so have increasingly emerged in the human rights and public health literature that help public health practitioners negotiate these difficult trade-offs. Thus, in considering whether a limitation on individual autonomy could be justified in the public interest, one would expect that:
- the objective of the policy, such as quarantine, has an objective of legitimate interest and is provided for in terms of a due legal process;
- the policy will be effective in realising that objective;
- the policy is strictly necessary in a democratic society to achieve that objective;
- there are no less intrusive means available to achieve the same objective; and
- the policy’s application is not arbitrary, discriminatory or unreasonable.

Often many public health measures are applied routinely without careful reflection as to whether these criteria are met. Calls for HIV notification, for example, are often made without clear policy objectives, or, where objectives are intended, without any evidence that notification will meet these objectives better than any other methods that are less restrictive of individual autonomy.

However, it is the case that, under certain circumstances, and given certain requirements being met, limiting rights for the public interest can well be justified in terms of international human rights law. Indeed, the limitation of rights may well be viewed differently when one realises that states have obligations imposed by international human rights law to positively realise various obligations to control the spread of infectious diseases (ICESCR, article 12) and to meet requirements for general welfare (ICCPR, article 4).

However, on another level, the public health objective itself is often the expression of a rights obligation of government to realise, for example, an environment not harmful to health (Section 24 of South Africa’s Bill of Rights), or the right of access to health care. Such socio-economic rights obligations are themselves necessarily collective in nature, and the trade off is not so much between individual civil liberties and public health objectives, but between different kinds of rights, such as individualist rights to autonomy, and social rights such as the those relating to health care access or a safe environment, both of which are needed to realise health. Protecting individual autonomy is important for the effectiveness of treatment programmes to ensure patient adherence and build trust in the health service, as much as social measures being required to control the spread of infectious diseases.

Popular misconceptions of rights as being solely or predominantly about civil liberties and formal parliamentary democracy have been fostered by a combination of the ascendance of neo-liberal economic policies in international policy making, as well as the unopposed exercise of power by the USA and its allies in the post-Cold War period in ways that entrench narrow individualist views of rights. Indeed, recognition of the indivisibility of rights and the equal importance of socio-economic entitlements and equity run counter to market-oriented development policies fostered by international development agencies.

Thirdly, human rights are not just about limits to state power but also speak to realising human potential in ways that confer agency.

When faced with public outcry or a health emergency, public health responses frequently fall back on traditional population interventions that obviate any role for individual and community action. The resort to autocratic traditions of central command and control has a strong anti-democratic history in public health and is based on a deep suspicion that humans can be trusted to make decisions in their own collective interest. It is not surprising, therefore, that many of the pioneering anti-smoking public health measures originated in the health programmes of Germany’s Nazi government and were entirely compatible with the ferociously anti-democratic and inhumane ideology of the Nazi regime. What a human rights approach brings to public health, therefore, is to ensure that social justice is a counterbalance to unchallenged utilitarianism, and that checks on power serve to protect the vulnerable, in ways that confer agency on communities to determine the policies and programmes that affect their health.

Increasingly, human rights advocates are realising that the sources of power in society who must be held accountable are not just states, but non-state actors, including multilateral agencies and multinational corporations whose de facto control of resources determines access to the conditions required for health to a far greater extent than does that of many states. International human rights law is increasingly providing “soft” law guidance through issuing of codes of conduct, norms and standards to ensure non-state actor accountability for human rights. Given that human rights are a product of developmental struggles, these frameworks will only be translated into meaningful instruments for accountability through strong civil society pressure on governments to turn such codes and standards into law.

Rights are not just about empowering vulnerable groups, but are themselves the products of contestation of power, at local, national and international level. And where power is contested, we should expect that the products of this contestation will reflect the relative balance of forces of different actors. For this reason, the exclusive emphasis on good governance, parliamentary democracy and civil liberties that has emerged as the dominant paradigm in some development discourses driven by Western governments has ironically contributed to a depoliticisation of rights and of development, because it strips struggles for health of any dimensions that challenge power imbalances – at local, regional and international levels. Yet power imbalances are what underlie health inequalities. This has led many to question “Why rights, why rights now?” since when the language of rights becomes denuded of power, it is turned into a technical exercise of compliance with norms.

Unchallenged, therefore, we should not be so naïve as to imagine that human rights will of necessity benefit poor people, poor communities or poor countries. Rather, by using and shaping rights towards pro-poor choices, human rights become transformative rather than simply easing human suffering. When human rights discourses, for example, begin to challenge and overturn obstacles posed by trade commitments to the realisation of the right to health, then the transformative nature of human rights emerges.

In this paradigm, the role of civil society organisation (CSOs) is absolutely central to realizing the agency that makes human rights approaches transformative. Yet many CSOs undertaking work in the health sector may 'do' human rights work, but are often not aware of the rights implications of their work on the ground. Is 'doing' human rights enhanced by 'acting' (i.e. conscious awareness of) human rights as well? Pilot research in the Western Cape with three health CSOs points to the multiplicative effect that a rights paradigm adds to their impact. By framing (health) needs as rights to which duty-bearers can be held accountable, not only is the demand for pro-poor services strengthened but beneficiaries of these services are enabled to be active agents in securing the conditions for their health, rather than passive recipients of state or NGO services. Moreover, placing demands in a right framework challenges service providers to see their role as realising states’ human rights obligations rather than simply delivering services. It is particularly in the field of socio-economic rights that the duality of service provision as fulfillment of human rights is evident and where it is clearest that human rights are more than just civil liberties.

CSOs engaging with rights approaches can build much stronger advocacy through sharing experiences and learning best practice. EQUINET, through its health rights theme, plans to explore the establishment of a learning network for CSOs in the region using rights approaches as a mechanism for enhancing civil society participation in the development of national health systems that are comprehensive, people-led and people-centred. We invite participation from CSOs and activists throughout the region in developing this network and look forward to your input and contribution to this debate.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org for attention to School of Public Health, University of Cape Town, Leslie London. Further information and publication on EQUINET work on health rights as a tool for health equity is available at the EQUINET website at www.equinetafrica.org.

Sub-Saharan Africa is the only region in the world where the absolute number and proportion of under-nourished children has increased in the last decade. East Africa is the sub-region experiencing the largest increases in numbers of underweight children –projected to increase by 36% from 1990 to 2005. Findings for stunting (chronic under-nutrition) and wasting (acute under-nutrition) are similar. Under-nutrition is the underlying cause of over half of child deaths. Even mild to moderate malnutrition can lead to significant deficits in cognitive and physical development.

One reason for the dismal nutritional status of children in Africa is the continual lack of food for many in the region. In less than four decades, Sub-Saharan Africa has been transformed from a continent that was a net exporter of food to one that is now heavily dependent on food imports. According to the Food and Agricultural Organisation, Africa’s food imports have risen from 8% in 1985 to 18% of world imports in 2001. A decline in agricultural and rural investment in Africa has led to a 12% decline in agricultural productivity for the workers in the region in the 1990s. Any growth in agricultural output has thus been achieved mostly from expanding the area under cultivation.

The United Nations Millenium Development Goals Hunger Task Team in 2004 summarised the consequences of this path to meeting food needs:
“Expanding the area under food production is inherently unsustainable, as the supply of new lands in densely populated areas of Africa is largely exhausted or must be maintained as natural systems for biodiversity conservation and other ecological services. The first effect in Africa and elsewhere in the tropics has been to expand into land that was previously available for fallows. Leaving land fallow allows land under cultivation the necessary time to recover from the effects of the crops taking nutrients from the soil. As a result of the reduction or elimination of fallows, soil fertility has fallen dramatically in many places, and yields are reducing with time. As the land becomes exhausted, there develops a serious tendency to continually sub-divide land among family members, which leads to smallholdings that are too small to produce a family’s food”.

Significantly, the yields of most important food grains, tubers and legumes (maize, millet, sorghum, yams, cassava and groundnuts) in most African countries are no higher today than in 1980. The environmental impacts of deforestation and drought, floods and the loss of topsoil are being compounded by the lack of investment. Only about 4% of land under cultivation in Africa is irrigated. This compares with 14% in Latin America and the Caribbean, a region with similar population densities and resource endowments. Fertilizer application is 15% lower today than in 1980. The number of tractors per worker is 25% lower than in 1980 and the lowest in the world. Africa’s share of total world agricultural trade fell from 8% in 1965 to 3% in 1996.

However, poor food security or poverty alone is not the whole story. Otherwise how does one explain the experience of many countries and populations that managed to achieve significant reductions in malnutrition before similar reductions in poverty? How does one explain the presence of malnutrition in situations where food is widely available? If one compares, for example, the experience in one region of Sri Lanka, Indonesia, the Philippines and Thailand, in the 1980s and 1990s, Sri Lanka and Thailand showed rapid improvement in nutrition, Indonesia showed slower but consistent improvement, and the Philippines little progress. Malnutrition in Latin America decreased from about 21% in 1970 to 7.2% in 1997, while income poverty decreased by only about 1% over the same time period.

Clearly reducing malnutrition is not solely dependent on increases in income. Gains in Latin America are attributed to good care practices (such as improved complementary feeding) access to basic health services, including family planning, safe water and sanitation and to women’s education and the cash resources they control.

Policies providing for female education, social safety nets, affordable food and public health services have contributed to improvements in nutrition even with minimal changes in poverty levels. In Sri Lanka, high levels of female education have been linked to improved child nutrition and child survival. Sri Lanka’s impressive performance in nutrition is also attributed to the establishment of social safety nets, especially the free or heavily subsidised distribution of rice, providing a minimum consumption floor. More recently, Save the Children UK in 2004 pointed to the universal, equitable and efficient public health system in Sri Lanka as an important reason for the low levels of maternal and child mortality in the country. Thailand incorporated nutrition as an important part of its National Economic and Social Development Plan (NESDP). This led to the establishment of an extensive community-based network of village health communicators and volunteers with existing village committees and leaders. These groups focus in communities on the fulfilment of basic needs such as optimal nutrition, provide education for this and monitor progress this through community-based growth monitoring.

A similar mobilisation of communities, health systems and national resources is required if we are to make a start in combating childhood malnutrition in Africa. This is an essential step if there is to be sustainable development in the region. Co-ordinated by the Health Science Research Council, EQUINET has embarked on a programme in east and southern Africa to collect and share information on case studies of how health systems address the wider social and economic factors affecting nutrition and lever action on these factors.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat email admin@equinetafrica.org. EQUINET work on food security and nutrition is available at the EQUINET website at www.equinetafrica.org. Work by the Medical Research Council of South Africa (MRC) is available at www.mrc.ac.za.