Investing in healthSjaak van der Geest

Health has traditionally been one of the major focus points in aid and development. Although prominently featuring in the MDG's, the investments in health are also criticised. It cannot be denied that investments in that sector have managed to increase health conditions in many countries, but it is argued that these hardly contributed to economic development. Conversely, some studies show that economic growth does increase health conditions.

If we are trying to look for causes of the differences in progress between sub-Saharan Africa and Asia, the low level of social development in health and education is the first cause that springs to mind. (from: Doing good or doing better)

Poor countries account for 56 percent of the global disease burden but less than 2 percent of global health spending. With the global commitment to the Millennium Development Goals in 2000, poverty and the deplorable health conditions of the world's poor have finally reached center stage in the international policy arena, and aid for health has greatly increased.

(From abstract: Schieber et al.2007 Financing Global Health: Mission Unaccomplished. Health Affairs 26 (4): 921–934)

Billions of dollars in aid are given every year to improve the health of the world's poor, and yet preventable diseases such as diarrhea and malaria continue to kill a child every thirty seconds and result in almost eleven million child deaths per year in poor countries. Pregnancy and childbirth continue to be a primary cause of death for women in developing countries, killing more than 500,000 women every year. More than twenty years into the AIDS pandemic, the disease is continuing to spread; in 2006 AIDS killed almost three million people, 380,000 of whom were under age fifteen. Tuberculosis, outpacing the medicines that exist to treat it killed 1.83 million people in 2006.

Opening paragraph : Schieber et al. (2007) Financing Global Health: Mission Unaccomplished. Health Affairs 26 (4): 921–934

Development policy and health

• Urgency of health

• Its short-term character: attractive to donors and politicians

• Health is an indicator of development

• Poor health is seen as an obstacle to development

Cultural (medical) anthropology

• Descriptive / ethnography• Understanding (cognitive, emotional,

moral)• Reluctance to ‘explain’ / predict• Approach: participant observation en

conversation• Sharing experiences on ‘the ground’ makes

modest

Multi-level perspective

• Different levels, different cultures (international; government; health service; households)

• Conflicting interests between level• Leads to conflictions ideas and actions• Aim: understanding one level in the context

of other levels• ‘Development interventionism’ (Verheijen)

Example 1:‘Unruly mélange’ (Buse & Walt 1997)

• Ideas and objectives of donors and ‘recipients’ (= governments) may be different / conflicting

• But what about ideas and objectives of govt, vs those of health workers & households???

• Authors seem to assume that govts represent the interests of these lower levels

Example 2: Monitoring use of essential drugs

• Evaluation by WHO of the success of its Essential Drugs Program (started in 1972)

• By reading policy documents of a number of selected countries

• Assumption was that if govt mentions ‘essential drugs’, essential drugs are indeed made available to patients.

Personal retrospect

• 1973. Birth control in Ghana

• 1980. Distribution and use of pharmaceuticals in Cameroon

• 1994-today. Experiences of growing old in Ghana (‘Money is man’)

• 1996-today. Sanitation and concepts of hygiene in Ghana

Money and medicine(s) (Cameroon)

• Paying implies appreciation of the value of medicine (as in ‘traditional’ medicine)

• Free dispension of medicines may lead to the opposite

• Paying produces awareness of consumer rights

• Where health care & medicines are free, patients have little leverage to address inefficiency or abuse (‘beggar has no choice’)

• Health insurance should also make clients aware of their rights

Nine stories of students’ research

• Francine van den Borne (Malawi)

• Getnet Tadele (Ethiopia)

• Esther Wiegers (Zambia)

• Jonathan Dapaah & Benjamin Kwansa (Ghana)

• Benson Mulemi (Kenya)

• Judith van de Kamp (Ghana)

• Agnes Kotoh (Ghana)

• Magi Matinga (South Africa)

• Janneke Verheijen(Malawi)

Francine van den Borne (2005) Trying to survive in times of poverty and AIDS: Women and multiple partner sex in Malawi. Amsterdam: Het Spinhuis.

• Mystery client approach• Poor women look for a male helper• To feed their families• Risking their own lives• Gender inequality• Poverty leads to hazardous sex (and HIV/AIDS)

Getnet Tadele (2005) Bleak prospects: Young men, sexuality and HIV/AIDS in an Ethiopian town. Leiden: African Studies Centre.

• Male youngsters between 15 – 24• Perceptions and practices love and sex (‘girls

want money’)• Within a broad social context (poverty, social

exclusion, police harassment)• Youngsters more concerned about day-to-day

survival than HIV/AIDS• Author’s pessimism regarding ‘solutions’ (p. 171)

Esther Wiegers (2008) Resilience and AIDS. Exploring resilience in the case of AIDS among female-headed households in Northern Zambia. Medische Antropologie 20 (2): 259-278.

• What is resilience?• Some ‘bounce back’, some don’t (4 narratives)• Why? Economic independence, social network,

access to ART, health insurance, marriage system.• Some engage in transactional sex (cf. Van den

Borne)• Emotional / psychological dimension of resilience.

Jonathan Dapaah & Benjamin Kwansa: PLWA in the community and in the hospital (Ghana). In progress

• Two-level study: hospital / community• Role of stigma: social consequences of revealing

HIV are worse than the sickness• ART is available but many refuse treatment for

fear of stigmatization• PLWA find a new ‘family’ in hospital• PLWA want to be peer supporters (also

counselling) but their experience expertise is under-valued (cf. Kober & Van Damme 2006)

Benson A. Mulemi (2010) Coping with cancer and adversity: Hospital ethnography in Kenya. Leiden: African Studies Centre.

• Next to hospital and treatment costs patients are worried about ‘additional bagage’ (family’s livelihood)

• Enormous social distance between doctors and patients

• Hospital is a place of hope and despair (collaps of health and livelihood)

Judith van de Kamp (2008) Aanpakken en wegwezen: Een antropologisch onderzoek naar de kortstondige inzet van gezondheidswerkers in ontwikkelingslanden. Master Thesis, UvA (text on line). See for English summary: Asking thém: Ghanaian health workers about Dutch short-term health workers in Ghanaian hospitals. Medicus Tropicus 50 -2: 6-7. (2008)

• Studied three categories of people involved in Dutch short-term health work in Ghana (long-term workers; short-term workers; local hospital staff)

• Debate in Dutch media• Well-meant assistance was regarded as harmful by other

parties• Ironic example of counterproductive health development

aid

Agnes Kotoh: Reaching the poor in health insurance (Ghana), in progress

• How to include poor people in health insurance?• Coverage is poor (ca 30% on average) in spite of

low premium (10 USD)• Common & covenient excuse: we have no money• But they do spend large amounts on funerals• More social and cultural pressure on funeral

‘insurance’ than on health insurance• Some people prefer to pay cash to get better health

care

Magi N. Matinga (2008) The making of hardiness in women’s experience of health impacts of wood collection and use in Cuntwini, rural South Africa. Medische Antropologie 20 (2): 297-311.

• Wood collection causes health problems (back pains, etc)

• Cooking on wood fire causes health problems (eyes, breathing, headache)

• Not simply result of poverty, even those who have electricity may continue to collect wood

• Culture perpetuates unhealthy practices

• Wood collection shows the good quality of a woman (hardiness)

Janneke Verheijen: Impact of food insecurity and female empowerment efforts on risky sexual behaviour in rural Malawi. In progress

• Assumption was: economic independence prevents women from risky sexual relations (cf. Verheijen 2007; Van den Borne; Wiegers)

• But: society does not allow a woman to remain unmarried (risk for married women)

• Economics is not sufficient condition for HIV/AIDS prevention

Tentative conclusions (1)

• Complexity and contradictions raise doubt about clear recommendations

• To evaluate health development we need to study all its organizational levels

• Economic problems and health problems are intertwined.

• 80% of child mortality is due to nutrition (WHO), so obviously agricultural and economic investment is a must.

Tentative conclusions (2)

• Economic development improves conditions for healthier living (but not always)

• Economic development improves coverage of health insurance (but not always)

• Economic development improves access to and use of health care (agency, consumer awareness, ability to pay)

• Free health care may not lead to better health (care)