PHA-Exchange> Poverty, Health and Development - Final document

[sunil.deepak at aifo.it]

Dear all,

On claudio's suggestion I am posting here the final document from an AIFO
workshop on Poverty, Health and Development held in 2001. I would also like
to remind that this document is part of a book published last year. Free
printed copies of this book are still available to those who will make
request (Send an email with full postal address to
<felicita.veluri at aifo.it>). Regards, Sunil Deepak, AIFO, Italy

POVERTY HEALTH & DEVELOPMENT WORKSHOP CONCLUSIONS

Poverty And Vulnerability:

Poverty is not related only to economic aspect but it is multi-dimensional.
It is related to powerlessness, to not being counted, to not being
considered, to be excluded, to be unheard. Poverty is related to
exploitation, oppression, victimisation and violence. It is also related to
migration, forced displacement, rising urbanisation, loss of livelihoods.

Poor are excluded from productive processes, are unaware about their own
rights and duties, lack self-confidence and lose their cultural identity.
Poverty is in lack of choice, instability and violence forcing people to
lose homes, livelihoods and belongings to become migrants, displaced and
refugees.

Among the poor, the more vulnerable are those who are dependent and who have
no say in decisions regarding their lives. These include women, disabled
persons, minorities (ethnic, religious or linguistic), refugees, old persons
without families, illegal emigrants, shelter-less and street dwellers,
landless peasants, persons associated with disease conditions like leprosy,
tuberculosis, AIDS, etc.

Social and cultural traditions can worsen the conditions of specific groups
like persons belonging to lower castes in certain parts of South Asia,
children victims of sexual and labour exploitation, widows, single mothers,
uneducated persons, wives of alcoholics, bonded (slave) labours, prisoners,
etc.

Criteria for measuring poverty and identifying the most vulnerable groups,
need to be adapted to each single context. Poor have limited access to food,
water, information and services like education and health. In rural
contexts, the materials and services are less available while it is
relatively easier to organise communities. In urban contexts, the material
and service availability is better but there are difficulties of access to
these by the poor, while there are additional problems of over-crowding,
violence, crime and substance abuse. In urban contexts, it may be more
difficult to organise communities. In both rural and urban contexts, the
rights of the poor and powerless are negated, while economic-alimentary
equilibrium is very fragile and there is increased vulnerability to
infections, ill health and disability.

Impact Of Changing Global Context:

Domination of free market economic philosophy based on maximising the
profits for those with power, worsening of ecological situation, growing
power of multinational corporations, weakening of national and local
decision making and weakening leadership roles for international
organisations like United Nations, World Health Organisation, etc. as well
as for national governments in developing countries, are some of the
characteristics of the present global context. At the same time, the power
of international financial organisations like World Bank, International
Monetary Fund and World Trade Organisation, who have assumed a major role in
deciding national policies for reducing national budgets for health,
education and social services, forcing structural adjustment programmes
requiring privatisation, promotion of vertical programmes and "services for
those who can pay" philosophy. These changes have seen an increase in the
number of the poor, making new poor and worsening the lives of the poor,
decreasing their access to services.

As far as voluntary organisations are concerned, availability of funds,
especially for promoting comprehensive and integrated development
programmes, has decreased. New organisations, consultancy firms and
foundations created by multinational and trans-national corporations, have
appeared, promoting specific single agenda vertical programmes for their own
image-building. The funding is usually for limited periods, focussing on
specific activities, without considerations about comprehensive health needs
of vulnerable target groups or sustainability, accompanied by unrealistic
performance targets, promoting universal standard recipes without an
understanding of local needs or situations. As far as health services are
concerned, while role of World Health Organisation is Marginalised,
organisations like World Bank have become the major players for funding
vertical single-agenda vertical programmes and research activities.

In the developing countries, the multi-national corporations and
international financial institutions find willing partners among some civil
society representatives like politicians and institutions, interested in
short term gains. Representatives of organisations and institutions working
for the poor and oppressed, challenging the policies and practices, which
worsen the lives of the poor, can face harassment, detention, violence and
even death.

At the same time, the new instruments and technologies of communication, can
give an opportunity for raising consciousness and organisation of poor
communities for influencing their own lives and the collective lives of
their communities as well as for a political change. Individuals and
organisations from both, South and North of the world, can promote advocacy
action to raise voice and create awareness about negative impact of
globalisation, such as the People's Health Movement.

EQUITY AND ACCESS TO SERVICES, ESPECIALLY HEALTH SERVICES:

Health has different dimensions - physiological, spiritual, physical,
mental, social and cultural. It is a result of interplay between individuals
and their environments. Health resides inside the persons, the primary units
of a health system. Health requires awareness about basic human rights and
the possibility to influence changes in the health service system so that
they respond to the basic health needs of the people. Health requires
participation of the different stakeholders including community members,
traditional healers, traditional birth attendants, health workers, local
artists, local community leaders, etc.

Health does not reside inside the walls of buildings of health structures -
inside these structures reside the pharmaceutical industries and curative
health care, which dominate and marginalise critical health action, health
information and preventive care.

Most of the national health budgets go to high technology institutions
catering to the needs of limited number of citizens while primary and
community health services receive a small percentage of available limited
resources. Primary and community health services may be inaccessible due to
long distances, lack of or high cost of transport, lack of qualified
personnel, high fees of the services, etc. The health personnel may work
with very low salaries, in some situations unpaid for long periods,
facilitated for working with vertical programmes promoted by international
organisations through payment of incentives and per-diems. Often, the
pharmaceutical industries promote unnecessary drugs and their combinations,
while ignoring the "unprofitable" essential drugs.

To improve the access of the poor and marginalised groups to the health
services, organisation of the communities and information about disease
prevention is necessary, so that communities can fight against factors
influencing negatively on the harmony between individuals and their
environments. While the health personnel needs training, community members
also need training. The organisations of the health services must involve
the beneficiary communities in the decision-making process. Preventive
medicine and traditional medicine need to be given more importance. At the
same time, organisations working with poor communities need to network,
share ideas and information, working together to ensure equal access for
different disadvantaged groups like women, children and persons with
disabilities.

Listening And Understanding The Voices Of The Poor:

The poor do not have power. The power is linked to access to information and
skills, access to funds, visibility and political strength. It is also
linked to brute force, like the men-women relationships, often with the
approval of traditions, culture and social support systems. Managers,
administrators, donors have more power the clients.

It is difficult to listen to voices of the poor, since their knowledge and
skills are not seen as useful or important. Project managers and donors feel
that they know the problems and the best solutions. The poor may not be
articulate or may not speak the language spoken by project managers and
donors. Project managers and donors do not have the time to stop or visit or
understand the living environments of the poorest. There are cultural
barriers to listening to the poor, who are seen as ignorant and uneducated.

Real development and transformation comes only if project managers and
donors can listen to their clients and discuss their own ideas with them.
Once the community is transformed, they will become the subjects of their
own development. It is not enough to visit the poor in their living
realities but project managers and donors need to live with them to
understand their concerns and ideas. Facilitating the communities to
organise themselves through activities like Self-help Groups (SHG) can be
useful.

Project proposals can not be developed simply from good intentions and
ingenuity, for this preparatory work in the communities is necessary and
skills of project managers are needed, who need to play the role of
catalysts. Networking and horizontal exchange of information between
self-help groups and community-based organisations is essential for their
capacity building. Identifying and involving community leaders is an
important part of reaching the communities.

There may be areas linked to traditions, cultures and social ethos of the
communities, with which project managers and donors may not agree. Changes
in such areas can come only through involvement and empowerment of oppressed
groups and victims, who need to become the protagonists for a social change.