|Essays on Food, Hunger, Nutrition, Primary Health Care and Development (AVIVA, 480 p.)|
|51. Can Significantly Greater Equity be Achieved through Targeting?: An Essay on Poverty, Equity and Targeting in Health and Nutrition. (*) (Food for a targetter's thought)|
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.