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Preface
Deborah Eade
Health and well-being are deeply personal. Nothing is more intimate than the experience of conceiving and bearing a child, and giving birth to a unique human being; none of us can live another's fear or pain; and death itself is something we cannot share, however real the grief we suffer. And yet, it is precisely when we or those close to us face illness or chronic suffering that we perceive how public an issue health is in reality. Policies about what level of health-care provision is guaranteed, what kinds of services will be offered, how priorities are established between competing claims, where resources are concentrated, and what alternatives are available, all become far more immediate when these affect us or our loved ones. Facing a particular health-related condition, and then being on the receiving end of the decisions or prejudices of others - be these health professionals, religious authorities, family members, neighbours, employers, or insurance companies - is something that often gives a new awareness of how limited is our capacity to control some of the most central aspects of our lives. It gives an insight into what exclusion feels like.
Disempowerment and exclusion are caused by a similar combination of deeply personal experience and circumstances on the one hand, and the social and political context on the other. The essays collected here show some of the complex ways and levels on which such exclusion operates, especially when people are already dealing with poverty and what this means for their health status. At one end of the spectrum, we see the importance of the macro-economic or ideological setting. Economic policies that result in the cutting of public services and the fragmentation of the regulatory role of government tend to lower the threshold of what is considered an acceptable minimum standard of health-care provision for the population at large. Rather than being a matter that combines the personal and the political, access to health care becomes one that depends on the individual's capacity to pay: patients are turned from citizens - who have rights and responsibilities - into clients or consumers who can (if they can afford it, and if anyone will insure them) take their custom elsewhere. The question of financing health care may thus be posed as a pseudo-technical one: what kinds of cost-recovery and insurance mechanisms 'work', and in what circumstances. The result is that the goal of 'Health for All by the Year 2000' is thereby eroded into 'health for those who can pay today'.
In seeking to harmonise market forces with people's health and well-being, we risk overlooking the underlying question of whether health can or should be treated as a commodity. The figures are grim. During the 1980s, the number of people living in absolute poverty rose to over one billion, with the gap in per capita income between the industrial and developing world growing threefold between 1960 and 1993. Each year, over 12 million children die of preventable causes before they become teenagers. Average life expectancy in the richest countries is expected to rise to 79 years by the turn of the century; while it is expected actually to fall to 42 years in some of the poorest. (1) It is a commonplace to say that poverty and ill-health are mutually reinforcing. And yet current trends suggest that 'the enjoyment of the highest attainable standard of health' which WHO describes as 'one of the fundamental rights of every human being' is seen almost as a by-product, something that will trickle down to the bottom some time in the future. There is a long way to trickle before this fundamental right reaches the one-fifth of humanity who are destitute, those who survive precariously in the informal sector, or those whose access to health care is limited by their age, their disabilities, or because of armed conflict. And while seven out of ten of the world's poorest people are female, women's health needs are systematically neglected regardless of their background. Yet, if development is not for health, what is it for - and who can expect to enjoy it?
Several essays in this compilation from Development in Practice examine the issue of exclusion from this angle. What are the forces that prevent women and men from taking advantage of the health services that are, theoretically, there for their benefit? Often the answers lie in the inappropriate ways in which such services are offered: expecting results too soon, ignoring other forms of knowledge and belief systems, imposing an agenda from above or outside, or failing to understand the complex social and power relations that affect people's behaviour and their expectations. A woman may have a right to ante-natal care, but if she does not know about it or why it matters, or if she cannot attend (whether because clinics are held at inconvenient times or inaccessible places, or because other family members do not allow her to go) then she may show up as a 'failure' in the midwife's performance. Exploring the many subtle ways in which disempowerment disables individuals and communities, the authors of the essays gathered here share their own practical experience of enabling people to develop the skills and the confidence to survive adversity, and to shape development in ways that better address their health and other needs.
Running through this volume are the issues addressed by Eleanor Hill in her introductory overview. How and why it is that people or aspects of health care are pushed to (or left in) the margins; but how often it is at these margins that ground-breaking (though unspectacular) achievements are made. Building on the insights of those who do not have power and status, and who lack many of the means to nurture their own health, reveals far more than the statistics can tell us about what is needed to ensure that development is for health - and about the consequences for humanity in failing to meet this challenge.
Notes
1 Figures taken from The World Health Report 1995: Bridging the Gaps, WHO, Geneva; and Human Development Report 1996, UNDP, Oxford and New York.
