Transcript Questions of health and inequality in Southern Africa

Questions of health and
inequality in Southern Africa:
the case of Mozambique
Bridget O’Laughlin
IESE April 2011
Argument
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The areas of connection between governance and health
are wider and less specialized than we often assume,
which becomes clear:
If we focus on the relation between health and inequality
rather than just the relation between health and poverty;
If we focus on health at the level of social causes of
health and disease rather at individual incidence of ill or
good health;
If we recognize that questions of health and inequality in
Southern Africa today have to do with broad historical
processes, and specifically some particular aspects of the
enduring political economy of this region.
The order of the lecture
 Some
illustrations of health inequalities in
Mozambique: the problem of rural health
 Different ways of thinking about the relation
between social inequality and health
 The political economy of inequality in health
in southern Africa: the rural ‘subsistenceproducing’ family can/must take care of
itself?
 The causes of Sick Populations: 3
examples
 Health and the space of governance
Under-five mortality rate/1000
rural
 urban
 Rural:urban ratio

Source: Equity Watch 2010 p. 14
1997
2008
270
166
1.6
162
135
1.2
Under-five mortality rate/1000 by wealth
quintile grouping
2003
 lowest
196.2
 2nd
199.8
 3rd
203.3
 4th
154.6
 highest
108.1
 rich:poor ratio 1.8 1.6
Source: Equity Watch 2010 p. 14
2008
171.9
169.2
169.1
136
109.9
Under 5 mortality rate (per 1000) by province 2010
Source: Equity
Watch 2010, p. 17
% Births attended by skilled personnel
Rural
 Urban
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
Urban:rural ratio
Source: Equity Watch 2010 p. 18
2003
2008
34.1
80.7
46
78.7
2.4
1.7
% Births attended by skilled personnel by
wealth quintile grouping
2003
 lowest
25
 2nd
33
 3rd
68
 4th
89
 highest
89
 rich:poor ratio
3.6
Source: Equity Watch 2010 p. 18
2008
36.1
45.0
52.9
66.2
88.3
2.5
Source: Adapted from Lindelow et al 2004, Table 53, p. 82
Percentage of users reporting access to alternative health
care providers by residence (2003)
Provider
Community health post
Hospital
Other health centre or post
Private for profit clinic
Nurse or doctor working from
home
Outside services from facility
staff
Religious organization or NGO
Traditional medical practitioner
Rural
Urban
3.3
1.9
18.6
70.5
34.7
67.7
0.4
10.4
0.8
2.9
0.0
1.7
20.0
14.5
76.4
51.2
0.3
38.5
5.0
12.2
Pharmacy outside facility
Market (that sells medicine)
Inequality in access to safe water and
sanitation
Equity Watch 2010 p. 31
Regional inequalities: improved sanitation
and safe water
Maputo city
Maputo
Gaza
Inhambane
safe water coverage 2003
Sofala
Manica
Improved sanitation
coverage by province 2005
Zambezia
Tete
Nampula
Cabo Delgado
Niassa
0
20
40
60
80
100
Source: Equity Watch 2010, p. 31
Rose’s distinction
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‘Aetiology confronts two distinct issues: the
determinants of individual cases and the
determinants of the rate of incidence’.
If we focus on the first issue, sick individuals, we
will try to protect high-risk individuals against
infections, whereas if we focus on the second
issue and follow a population approach we will
seek to control the causes of incidence.
Source: Rose 2001: p. 427
Mosley & Chen Critique of approaches to Mortality
Source: Mosley & Chen
Mosley & Chen Alternative
Modelling AIDS Mortality
Socio-economic determinants
Indirect Influence on morbidity
and mortality
Proximate determinants
(bio-medical factors affecting):
exposure to HIV
infection by HIV
immune system collapse
Direct Influence on morbidity
and mortality (Cost-efficient policy focus)
AIDS mortality
Cordell & Piché (adapted):
demographic regimes as outcomes
Political economy
Health
environment
Direct causes of
death
Demographic
regime
State policies and
practices
Water quantity and
quality
Parasitic disease
fertility
Civil society
organisations
policies and
practices
Sanitation and
waste disposal
Infectious disease
mortality
Social Class
nutrition
Degenerative
disease
migration
Gender relations
Preventive health
care practices
Congenital disease
Illness treatment:
personnel, services,
supplies
suicide
Violence
accidents
Social costs of production
 the
ones normally counted as factors of
production AND
 a wide range of costs which in some
societies and at some times are counted as
production costs, and at other times are borne
by the state, or workers' families, or the entire
population.
Source: Feierman 1985
Southern Africa:
‘Africa of the Labour Reserves’
Migrant labour
 Small-holder cash-cropping and livestock
production
 The myth of subsistence farming
 Who bears/pays the social costs of
production?

Southern Africa
Causes of cases and causes of
incidence
The development of endemic tuberculosis
in Southern Africa
 The elimination and recurrence of malaria
in Swaziland
 The mystery of konzo paralysis
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Health and the space of governance
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The health of populations is determined by a terrain much
broader than formal health care (preventive and curing) :
nutrition, work, environment
 Strategies of accumulation
 Strategies of redistribution
the instruments of governance of the state include all those
of particular relevance in approaching social inequality
 tax policy,
 industrial relations policy,
 corporate governance policy,
 financial regulation
 social transfers
The space of health governance is a terrain of struggle
reaching civil society and the state
MDG 4
Under-five mortality rate (probability of dying by age 5 per 1000 live births)
2000
2008
3
1
28
21
165
165
African Region
98
85
Region of the Americas
22
15
South-East Asia Region
63
48
European Region
18
12
Eastern Mediterranean Region
66
57
Western Pacific Region
28
18
Low income
88
76
Lower middle income
55
44
Upper middle income
26
19
7
6
54
45
124
52
90
48
Ranges of country values
Minimum
Median
Maximum
WHO region
Income group
High income
Global
Mozambique
South Africa