Nadine Gasman and Maxine Hart
INTRODUCTION
The 1999 United Nations Human Development report begins: 'The real wealth of a nation is its people. And the purpose of development is to create an enabling environment for people to enjoy long, healthy and creative lives. This simple but powerful truth is too often forgotten in the pursuit of material and financial wealth.'
The current trend of globalisation has contradictory implications. While the last 50 years have witnessed developments that augur better for the future of humanity-child death rates have fallen by half since 1965, and a child born today can expect to live a decade longer than a child born 20 years ago; the combined primary and secondary school enrolment ratio in developing countries has more than doubled-the world faces huge amounts of deprivation and inequality. Poverty is everywhere. Measured on the human poverty index-more than a quarter of the 4.5 billion people in developing countries still do not enjoy some of life's basic rights-survival beyond the age of 40, access to knowledge and adequate private and public services.
The quickening pace of globalisation has generated enormous social tensions that development policies have failed to tackle. The underlying assumption has been that once economic fundamentals are corrected, social issues will resolve themselves of their own accord, and that well-functioning markets will not just create wealth, but will also resolve problems of human welfare.
Current events reveal with awful clarity the depth of this fallacy. Millions of people are poorer than ever before, with growing indices of inequality between countries and within countries. Most countries report erosion of their social fabric, with social unrest, more crime, and more violence in the home.
Neoliberal advisors in the 1980s developed a vision of the ideal country: its economy would be largely self-regulating through open competition between private firms; its public sector would be relatively passive-providing the minimum services necessary to conduct private business efficiently and to protect society's weakest members.
This dogmatic economic prescription, concludes the United Nations Research Institute in Social Development (UNRISD), has not only had limited value, but has been dangerous. Even those countries that have been held up as economic success stories have been social failures. Most people in highly indebted African and Latin American countries have suffered a sharp drop in living standards.
Between 1980 and 1990 the per capita income declined markedly in developing countries. An International Labour Organization study of 28 African countries showed that the real minimum wage fell by 20% and more than half of Africa's people now live in absolute poverty. In most Latin American countries the real minimum wage fell by 50% or more. Coupled with this, people have suffered from severe cuts in public services-affecting nutrition, health, education and transport.
The UN Human Development Report of 1999 goes further: a comparison between the size of income of the fifth of the world's people living in the richest countries and that of the fifth in the poorest showed a ratio of 74 to 1 in 1997, up from 60 to 1 in 1990 and 30 to 1 in 1960.
The advocates of adjustment had hoped for a trade-off: long-term economic gain in return for short-term social cost. What they did not foresee was that the social impact could itself frustrate the desired economic effect. This temporary sacrifice for the poor is beginning to look like a permanent intensification of poverty.
UNRISD explains: 'When the market goes too far in dominating social and political outcomes, the opportunities for and rewards of globalisation spread unequally and inequitably-concentrating power and wealth in a select group of people, nations and corporations, marginalising others. Globalisation in this era seeks to promote economic efficiency, generate growth and yield profits. But it fails on the goals of equity, poverty eradication and enhanced human security.'
Economic growth, an important input for human development, can only translate into human development if the expansion of private income is equitable, and only if growth generates public provisioning that is invested in human development-in schools and health centres rather than arms. Reduced public spending weakens institutions of redistribution-leading to inequalities.
THE FUTURE
We face the challenge of setting up rules and institutions for stronger governance-local, national, regional and global-that put the health and well-being of each individual, community and nation at the centre. We need to create enough space for human, community and environmental resources to ensure that development works for people and not just for profit.
Globalisation expands the opportunities for unprecedented human advance for some, but shrinks those opportunities for others and erodes human security. It is integrating economies, culture and governance, but is fragmenting societies and ignoring the goals of equity, poverty eradication and human development.
Overcoming poverty must be seen as the main ethical and political challenge. Experience shows that the most appropriate programmes are long-term initiatives of a comprehensive/ multi-dimensional and multi-sectoral nature, aimed at breaking down the mechanisms that perpetuate poverty from one generation to another.
Development patterns need to be oriented to make equity-that is, the reduction of social inequality-the central pillar. This should be the basic yardstick against which we measure development. Education and employment present two master keys for development. Education has an impact on equity, development and citizenship, and therefore needs to be assigned top priority in terms of social policy and public spending, especially important is education of girls. Latin American studies have indicated that 11-12 years of schooling (completed secondary education) are required if people are to have a chance of escaping poverty. At the same time, a high-quality job-creation process needs to be put in place.
Some questions?
What are the social factors that influence the health situation in your community or countries?
Is violence a problem in your community?
What is the status of Women and children?
Is government responding to the people's needs? Why?
1. Editorial
2. Equity in Health
Measures to protect people in developing countries from being exploited in medical research trials may prevent some projects going ahead that could improve the health of poor people, a leading scientist has warned.
The Angolan government plans to launch an HIV/AIDS testing and counselling project to analyse the prevalence of the disease in the country, official news agency Angop has reported.
The tobacco industry claims to employ 30 million people worldwide. But it produces a product that has serious health implications for millions more. Governments are negotiating new international controls. This website helps you to understand the health, political and economic issues at stake as tobacco goes on trial.
The Botswana government may soon test all prospective students for HIV/AIDS, reported the 'Botswana Gazette' on Thursday. Addressing first year students of the University of Botswana last week, career guidance officers from the Ministry of Education said the government was considering testing students compulsorily.
Botswana has one of the world's highest percentages of people living with HIV/AIDS. Latest figures from UNAIDS suggest more than 35 percent of Botswana's adult population carry the virus. Stigma and denial remain huge impediments to fighting the disease. A recent government report found that many Batswana still believe that HIV/AIDS was a foreign disease, which is not in Botswana or is only found in urban areas. Head of the National AIDS Coordinating Group (NACG), Babu Khan, spoke to IRIN about the challenges associated with tackling the epidemic.
A World Bank study on tobacco in developing countries. "Developing countries can prevent millions of premature deaths and much disability if they adopt measures to reduce the demand for tobacco" according to the study. "To effectively reduce demand, governments can raise cigarette taxes, ban the advertising and promotion of tobacco products, and provide information on the health risks smoking causes directly or through research."
Argentina, Brazil, Colombia, the Dominican Republic, Indonesia, Nigeria, South Africa and the Philippines are experiencing a "minor epidemic of birth defects" because poor women are taking misoprostol in an attempt to end their pregnancies, the New Scientist reports.
In the first half of 2000, the German national AIDS organization Deutsche AIDS-Hilfe e.V. (DAH) in Berlin presented the results of a study into international entry and residence regulations and the availability of medical treatment for people with HIV infection and AIDS. DAH had succeeded in collecting information from 166 countries. The results are disturbing.
As the legal campaign against the South African government’s decision not to provide antiretroviral drugs grows apace, it has emerged that the manufacturer of one of the drugs is about to supply the drug free of charge.
Ghana hopes to begin manufacturing generic versions of HIV/AIDS drugs soon, the Accra radio JOY FM reported Minister of Health Richard Anane as saying. Two local pharmaceutical companies have been short-listed but the government plans to contract only one.
Pages
3. Human Resources
By James D. Shelton
For more than 20 years, the family planning and reproductive health field has promoted the understanding of the "user perspective,"1 and rightly so. We've learned that in order to have successful programs that serve clients well, we need a better understanding of the people being served. But what of providers? Although providers are obviously essential partners in service programs, their perspectives have received remarkably little attention. That is a major gap. In the early 1990s, the International Planned Parenthood Federation (IPPF) put forward its seminal work on the "needs of the provider" to complement its "rights of the client."2 But to improve programs further, we need to see the world through the providers' eyes and understand them better. Who are they? How do they see their jobs, their roles and their programs? What are their needs and motivations? What aspects of their work environments challenge them? What is the human dimension of their overall lives, and how can we best enlist their help to improve access to services and the quality of programs?
Urban Institute - August, 2001, Washington, D.C., USA.
A new Urban Institute report on workers without health insurance suggests that the most efficient way to increase coverage is to target subsidies toward low-income workers. The report offers the most detailed picture yet of the uninsured working population—now numbering more than 16 million—and compares the relative merits of two key vehicles for expanding coverage: tax credits or public programs. Researchers Bowen Garrett, Len Nichols and Emily Greenman, characterizes today’s uninsured and examines the policy implications. The report, based on analyses of 1999 Current Population Survey data and a survey of the literature on the working uninsured, was developed for the W.K. Kellogg Foundation as part of its Community Voices: HealthCare for the Underserved initiative series.
4. Public-Private Mix
The Congress of South African Trade Unions' (Cosatu's) strike action against privatisation has placed a large question mark over the effectiveness of South Africa's efforts to privatise parastatals - or at least communicate to the broader community the need to restructure.
BMJ September, 2001 )
Three objectives are recommended in relation to the private provision of care for conditions of public health importance: widening access, improving quality, and ensuring non-exploitative prices. None of these will be simple to achieve; and multifaceted interventions, involving policymakers, providers, and users will be required. Increasingly service users (or "consumers") are being highlighted as the key to driving improvements to achieve these goals. Their role has, however, been little evaluated in developing countries.
Roy Widdus, Public–Private Partnerships for Health, Global Forum for Health Research
Bulletin of the World Health Organization, August 2001, 79 (8)
A large variety of public–private partnerships, combining the skills and resources of a wide range of collaborators, have arisen for product development, disease control through product donation and distribution, or the general strengthening or coordination of health services. Administratively, such partnerships may either involve affiliation with international organizations, i.e. they are essentially public-sector programmes with private-sector participation, or they may be legally independent not-for-profit bodies. These partnerships should be regarded as social experiments; they show promise but are not a panacea. New ventures should be built on need, appropriateness, and lessons on good practice learnt from experience. Suggestions are made for public, private, and joint activities that could help to improve the access of poor populations to the pharmaceuticals and health services they need.
5. Resource allocation and health financing
Leon DA, Walt G, eds. New York, NY: Oxford University Press, 2001.
The editors identify four themes: health consequences of social and economic change; conceptual issues associated with health and wealth, including the role of health services; emerging and neglected priorities, e.g., the significance of mental illness and injuries; and evidence for policy and interventions. The role of the health care system is considered to be a central issue. The editors argue that access to health care is typically viewed as being more likely to affect health differences in developing than in developed nations, where, relatively speaking, access is more readily available. In contrast, in the developed world, health disparities, they argue, are more likely to be viewed as being due to differences in lifestyle and environmental exposures. Later, they acknowledge that health disparities, in fact, are due to the independent and joint effects of access to health care, as well as to other factors, including lifestyle and the effects of the physical environment.
David M. Dror, International Labour Organization (ILO) Bulletin of the World Health Organization, July 2001, 79: 672–678.
Deficient financing of health services in low-income countries and the absence of universal insurance coverage leaves most of the informal sector in medical indigence, because people cannot assume the financial consequences of illness. The role of communities in solving this problem has been recognized, and many initiatives are under way. However, community financing is rarely structured as health insurance. Communities that pool risks (or offer insurance) have been described as micro-insurance units. The sources of their financial instability and the options for stabilization are explained. Field data from Uganda and the Philippines, as well as simulated situations, are used to examine the arguments. The article focuses on risk transfer from micro-insurance units to reinsurance. The main insight of the study is that when the financial results of micro-insurance units can be estimated, they can enter reinsurance treaties and be stabilized from the first year. The second insight is that the reinsurance pool may require several years of operation before reaching cost neutrality.
Harvey Whiteford, M. Teeson, R. Scheurer, Dean Jamison. CMH Working Paper No. WG1 : 12, July 2001 Commission on Macroeconomics and Health, WHO
Mental Disorders are found in all cultures, are prevalent, cause considerable disability and rank high on the league table of world disease burden. By extension, they constitute a significant economic burden in all countries. Better understanding the extent of this economic burden and the development of frameworks to deliver cost effective interventions will provide a basis for programs which not only reduce the disability associated with these disorders but also promote human development and economic productivity. International agencies such as the World Health Organisation are intensifying their focus on mental illness with the World Health Report 2001 dedicated to mental health. The World Bank has identified neuropsychiatric disorders as an important emerging public health problem for developing market economies.
6. Governance and participation in health
Third World Network, Oxfam International and Health Gap Coalition are launching a global online petition which we hope will demonstrate the strength of global public support for WTO patent rules that put people before the profits of powerful drug companies. The petition is addressed to George Bush as a leading international figure whose government is blocking changes and clarifications to the TRIPS Agreement that would mean cheaper medicines for people in developing countries. The petition will run from September 1st through to the WTO Ministerial in Quatar in November where it will be handed over to the US Government. Sign and support the petition which is online at the Oxfam website.
7. Monitoring equity and research policy
Boston, MA, USA - December 7 - 9, 2001. Health Policy Statistics Section (HPSS) - American Statistical Association.
The conference provides a forum for discussing research needs and solutions to the methodological challenges in health services research. Its specific aim is to create the interface for methodologists and health service researchers. The Program will cover several technical areas including hierarchical models, longitudinal data, causal inference, techniques for assessing quality of care and for profiling providers, techniques for inferring disparities, decision making, data mining, and survey design. The deadline for abstracts: September 17, 2001.
Stuck for a punchy conclusion to a scientific paper? Best avoid the mantra 'more research is needed' - a US epidemiologist has now devised a way to work out whether, for any given study, this claim is justified.
8. Useful Resources
Fogarty International Center National Institutes of Health - USA
The National Institutes of Health is one of many public and private organizations across the globe that provide international support for biomedical research and training. Since 1988, the Fogarty International Center has published the Directory of International Grants and Fellowships in the Health Sciences. This directory is a comprehensive compilation of international opportunities in biomedical research.
300+ publications (more than 30.000 pages) of
food, nutrition, food policy and research is available on CD from international organisations supplied by Human Info NGO in Belgium. The costs participation system is designed to maximize redistribution by partner multipliers who purchase 70 up to 900 and redistribute them free.
Looking for the latest information on female genital mutilation? Need a journal article on adolescent reproductive health and HIV/AIDS?
Trying to track down an article on population and the environment? The answers to these questions and much more are now just a few mouse clicks away on the new Internet POPLINE database. POPLINE, the world's largest bibliographic database on population, family planning, and related issues, is now available free of charge on the Internet. All 280,000 citations, representing published and unpublished literature, can be accessed for no charge.
2 CDs on African nutrition are available from Dr Britta Ogle, Dept of Rural Development Studies, Swedish University of Agricultural Sciences, P O Box 7005, 75007 Uppsala, Sweden. The costs are free but there is limited availability so
priority will be given to Africans. The CD Roms can be copied.
The International Network for the Availability of Scientific Publications (INASP) is pleased to announce the completion of the first phase of the Programme for the Enhancement of Research Information (PERI). This is an important programme aimed at the wider access and dissemination of scientific and scholarly information and knowledge with and between developing and transitional countries. Researchers, academics, scholars and librarians in Ghana, Tanzania and Uganda are now invited to access current awareness databases, full-text online journals and document delivery for free.
ESRC/ Economic and Social Research Council and British Academy, London, UK - 2000
An inquiry into the relationship between science and the media, presents an agenda of current issues for examination by social science researchers, science policy experts, the media and scientists.
9. Jobs and Announcements
UCT is seeking a senior Family Medicine Physician with appropriate postgraduate qualifications, and clinical experience in urban and rural settings for this post for appointment as soon as possible.
The successful candidate will have proven research, teaching, clinical and managerial ability in this field. She/he will need to play a major role in the restructuring of the regional joint health services teaching platform, affecting training and research programmes in the
faculty, and district based public sector health services. This will include leading and developing the present Division of Family Medicine in the School of Public Health and Primary Health Care, and involves undergraduate and postgraduate programmes, initiating an active research programme, and promoting staff development. Closing date: 21 September 2001.
Closing date for applications: October 20 2001
The Regional Network for Equity in Health in Southern Africa (EQUINET) has played a role over the past three years in highlighting issues of equity in health in southern Africa. It does so by networking professionals, civil society and policy makers to promote policies for equity in health, undertaking research, initiating conferences, workshops, and discussions through the internet, and providing inputs at the SADC forums.
Noting the already significant work taking place on poverty, poverty reduction strategy papers and the links to health, and equally the strength of policy commitment to equity in health, and noting work already done by EQUINET in this area (which will be provided), EQUINET seeks to commission a paper to inform policy and research work on poverty, equity and health in southern Africa. More specifically the paper should address the following issues:
1. Using existing work done by EQUINET, WHO etc on poverty-equity-human rights links, briefly outline a conceptual framework relevant to public policy and practice for linking poverty and equity in health in southern Africa, where both poverty and inequality are extremely high. This should show both the points of distinction and of linkage between poverty and equity.
2. Identify from this, and supported where possible by evidence gathered by EQUINET, MAP and major poverty monitoring initiatives, where public policy priorities lie in dealing with the poverty-equity issues in health.
3. On the basis of the above, discuss the specific health sector measures / policies and features of policy processes that are pro-poor or enhance equity outcomes and those that exacerbate both inequity and poverty.
4. Critically assess the extent to which these measures and processes are present in PRSPs in southern Africa (using available web documentation of PRSPs and PRSP processes) and the implications for ensuring that PRSPs better integrate poverty-equity linkages.
Time frame: Six months, with an expected work time of three months.
Fee: Usd4 500
Process: Applicants are asked to submit a proposal for the grant that includes
i. a CV, clearly identifying previous work and documents authored in the areas of poverty, equity and health
ii. a sample of a paper produced by the applicant
iii. in one page a list in bullet form of the points to be considered in preparing the conceptual outline in item (1) of the paper and a paragraph of the broad issues most likely to be covered in item (4)
Applications should be sent, with contact postal, fax and email address to
TARSC 47 Van Praagh Ave, Milton Park, Harare, Zimbabwe
Ph: 263-4-708835 Fax: 263-4-737 220 Email: rloewenson@healthnet.zw
The Partnership for Global Health Equity is a small grants facility created to provide seed funding for Canada-South partnerships that involve the production or utilisation of equity-oriented research for health. The Partnership is housed at the International Development Research Centre (IDRC) and has a number of contributors, including IDRC, RITC, CIDA, CSIH, CPHA, and other Canadian and developing country health research organisations. The inaugural October 2001 competition will be administered by the Canadian Society for International Health. The Partnership seeks to encourage a range of innovative health research related activities and partnerships that are focussed on the health priorities faced by Southern countries and are pro-equity, gender-sensitive, participatory, and trans-disciplinary. Priority research areas include tobacco control policy, population health and community-based approaches to HIV/AIDS and other infectious diseases, health equity, and globalisation and health. The Partnership intends to fund research whose current theme, approach, and/or partnerships do not readily fit under already existing funding frameworks, and thus to identify some of the current gaps in health research funding and to explore mechanisms to increase the resources available for important and innovative health research activities. The application deadline is October 1st 2001.
The Institute of Development Studies, UK, is seeking to appoint two or three researchers to strengthen and expand its health and social change team. We encourage applications from outstanding applicants with a broad interest in issues of health and development. We particularly encourage people who can contribute to our work on one of the following: gender and health equity, health sector reform and development in China, or new approaches to health development in Africa. Closing Date: 8th October 2001. Interview Date: 29th & 30th October 2001.