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POVERTY AND HEALTH RESEARCH CHALLENGES FROM THE

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					              PLENARY POVERTY AND HEALTH RESEARCH
      CHALLENGES FROM THE PERSPECTIVES OF THE POOR AND SOCIAL
                           EXCLUDED - I
              HANDLING CONTEXT SINCE 1990s
•   Poverty
•   Social and Economic inequalities (between and within countries and people)
•   People moving into poverty
•   People socially excluded or marginalized
•   Health consequences of poverty and marginalized are better documented
•   New economic policies weakening state commitment to health of the poor
•   Health sector reforms eroding effectiveness of weak public health system -
    particularly for poor
•   Unregulated private sector growth undermining poor people’s access to health


                        EMERGING CONSENSUS

                            GFHR FORUM 7 - Ravi Narayan,
                                     PHM
              PLENARY POVERTY AND HEALTH RESEARCH
      CHALLENGES FROM THE PERSPECTIVES OF THE POOR AND SOCIAL
                           EXCLUDED – II
                IMPERATIVES FOR RESEARCHERS

•   Measuring ‘poverty’ - WHAT & HOW
•   Contextualising ‘poverty’ in our problem analysis
•   Capturing the realities of poor people’s lives
•   Keeping ‘poor and marginalised’ in context when concluding
     - Access to health interventions
     - Effects of health interventions
     - Recommendations from operational or health system research

* Going beyond bio-medical determinism to social determinants like :
     - Class
     - Gender
     - Stigma
     - Ethnic discrimination
     - Access and denial
      - Human rights violation
     - Violence, etc


                                     GFHR FORUM 7 - Ravi Narayan,
                                              PHM
     PLENARY POVERTY AND HEALTH RESEARCH
CHALLENGES FROM THE PERSPECTIVES OF THE POOR AND
             SOCIAL EXCLUDED – III A
    GRASSROOTS PERSPECTIVES




              GFHR FORUM 7 - Ravi Narayan,
                       PHM
         PLENARY POVERTY AND HEALTH RESEARCH
    CHALLENGES FROM THE PERSPECTIVES OF THE POOR AND
                 SOCIAL EXCLUDED – III B
   REACHING THE POOR - UNDERSTANDING
              THEIR LIVES
• NUTRITION INSECURITY
• RURAL / URBAN INDEBTEDNESS
• HEALTH CARE EXPENSES
• PUBLIC HEALTH / PRIMARY HEALTH CARE DEVALUATION
• EXPLOITATION BY COMMERCIAL MEDICAL / HEALTH CARE
• ENVIRONMENTAL DEGRATION
• UNEMPLOYMENT

   (Do our research strategies and protocols capture
                          or
             contextualise these aspects?)
                  GFHR FORUM 7 - Ravi Narayan,
                           PHM
             PLENARY POVERTY AND HEALTH RESEARCH
     CHALLENGES FROM THE PERSPECTIVES OF THE POOR AND SOCIAL
                          EXCLUDED - IV
                                   CASE STUDIES

•   HEALTH AND SOCIAL EXCLUSION
    (DALITS and ADIVASIS in INDIA)

•   GLOBALISATION AND ITS EFFECT ON WOMEN

    (gender approach to Health)


•   INDEBTEDNESS AND ILL HEALTH

•   SOCIAL CONSEQUENCES OF TB

•   BEDNETS FOR THE POOR

•   ASSAULT ON THE BASIC DETERMINANTS OF HEALTH
                                  GFHR FORUM 7 - Ravi Narayan,
                                           PHM
         PLENARY POVERTY AND HEALTH RESEARCH
    CHALLENGES FROM THE PERSPECTIVES OF THE POOR AND
                 SOCIAL EXCLUDED – IVA
DIFFERENTIALS IN HEALTH STATUS AMONG THE
          MARGINALISED GROUPS
                                          indicators


         GROUPS          INFANT        UNDER 5         % OF CHILDREN
                         MORTALITY /   MORTALITY /     UNDERWEIGHT
                         1000          1000
         STs             84.2          126.6           55.9


         SCs             83.0          119.3           53.5


         OBCs            76.0          103.1           47.3


         Others          61.8          82.6            41.1


         All (India)     70.0          94.9            47.0




                       GFHR FORUM 7 - Ravi Narayan,
                                PHM
                 PLENARY POVERTY AND HEALTH RESEARCH
            CHALLENGES FROM THE PERSPECTIVES OF THE POOR AND
                         SOCIAL EXCLUDED – IV B
    GLOBALISATION AND ITS EFECTS ON WOMEN
•   Women work force in informal
     –   - Unorganized sectors
     –   - Lack of social security
•   Commodification of women
•   Violence & crime against women
•   Rising cost of health care
     –   - Home care
     –   - Work for women
•   State Government subsidy to Health
•   Glorification of technology
•   Primary Health Care
•   Preventive and Promotive Care
•   Role of international / donor agencies in policy       (negative influences)




                                     GFHR FORUM 7 - Ravi Narayan,
                                              PHM
             PLENARY POVERTY AND HEALTH RESEARCH
        CHALLENGES FROM THE PERSPECTIVES OF THE POOR AND
                     SOCIAL EXCLUDED – IV C
          INDEBTEDNESS AND ILL HEALTH

• A   HOUSEHOLD              INDEBTEDNESS             POVERTY CYCLE
      ILL HEALTH

        PUBLIC SECTOR                           POVERTY

        MEDICAL / HEALTH CARE                   ALLEVIATING EFFECT


• B. NATIONAL / INTERNATIONAL DEBT
• Lowered Life Expectancy
• Debt Repayment 3-4 times health expenditure
                                                              (BMA, 2000)


                       GFHR FORUM 7 - Ravi Narayan,
                                PHM
             PLENARY POVERTY AND HEALTH RESEARCH
        CHALLENGES FROM THE PERSPECTIVES OF THE POOR AND
                     SOCIAL EXCLUDED – IV D
             SOCIAL CONSEQUENCES OF TB

• Adverse economic effects (57%) mortgaging, selling
  assets, taking loans.
• Disability and inability to work (26.5%)
• Adverse effects of above on treatment (53%) delayed,
  irregular, incomplete.

DISEASE ISPOSSESSION          DISABILITY              DISCONTINUATION

                            of treatment

    THESE ASPECTS ARE SUBMERGED BY THE PREDOMINANTLY
     TECHNICAL FRAMEWORK OF TB CONTROL STRATEGIES
                       GFHR FORUM 7 - Ravi Narayan,
                                PHM
          PLENARY POVERTY AND HEALTH RESEARCH
     CHALLENGES FROM THE PERSPECTIVES OF THE POOR AND
                  SOCIAL EXCLUDED – IV E
TRIBAL POPULATION BEHAVIOUR IN MANDLA (MP)
            (in relation to bed net use)
           COMMUNITY SURVEY
NIGHT MAHUA COLLECTION     16%
SLEEP IN FIELDS            12%
TENDU LEAF COLLECTION      21%
FISHING                    8%
   (1,200 PEOPLE OUT BEFORE DAWN OUT OF 2000)
                                         Singh, N, Mishra, A.K., Khan M.T. 1992
                                    in Community Participation in Malaria Control
                                            V.P. Sharma (Ed) MRC (ICMR) 1993

           (Malaria is a poverty issue as well!)
                  GFHR FORUM 7 - Ravi Narayan,
                           PHM
                PLENARY POVERTY AND HEALTH RESEARCH
           CHALLENGES FROM THE PERSPECTIVES OF THE POOR AND
                        SOCIAL EXCLUDED – IV F
       ASSAULT ON DETERMINANTS OF HEALTH
•   Privatisation of water
           Increased water cess; buying up of rivers;
           pollution of rivers
           bottled water costing more than milk.
•   Onslaughts on the environment
           Corporate liability
•   Primary commodity crop prices crash
           rural / agricultural distress & impoverishment
•   Lifting of quantitative restrictions / tariff
           reductions - cottage industries / small scale industries affected
•   Increased conflict, violence, war
•   Increased marketing of health risks
           alcohol, tobacco, junk foods, unhealthy lifestyles



                                     GFHR FORUM 7 - Ravi Narayan,
                                              PHM
          PLENARY POVERTY AND HEALTH RESEARCH
     CHALLENGES FROM THE PERSPECTIVES OF THE POOR AND
                   SOCIAL EXCLUDED – V
 ‘REDISCOVERING ALMA ATA DECLARATION’

• FOCUS ON EQUITY
     Disaggregating data
     Collecting social - economic - cultural - political evidence

• FOCUS ON APPROPRIATE TECHNOLOGY
     Is it relevant to lives of poor?
     Cost? Access? Social control?



• FOCUS ON INTER-SECTORAL APPROACH
     Are there factors beyond bio-medical Epidemiology to explain the evidence?


• FOCUS ON COMMUNITY PARTICIPATION
     Is the community involved in the situation and problem analysis?
     Is the community involved in interpreting the data?


• FOCUS ON HEALTH AS A RIGHT
     Does your research finding reach people / community to empower them?




                                  GFHR FORUM 7 - Ravi Narayan,
                                           PHM
                 PLENARY POVERTY AND HEALTH RESEARCH
            CHALLENGES FROM THE PERSPECTIVES OF THE POOR AND
                          SOCIAL EXCLUDED – VI
   TB AND SOCIETY : LEVELS OF ANALYSIS AND
                 SOLUTIONS
LEVELS OF ANALYSIS OF TB         CAUSAL UNDERSTANDING                   SOLUTIONS / CONTROL
                                                                            STRATEGIES


Surface phenomenon               Infectious disease / germ theory     BCG, case finding and
                                                                      domiciliary chemotherapy


Immediate cause                  Under-nutrition / low resistance,    Development and welfare –
                                 poor housing, low income /           income generation, improved
                                 purchasing capacity                  housing, social security
Underlying cause (symptom of     Poverty / deprivation, unequal       Land reforms, social movements
inequitable social relations)    access to resources


Basic cause (deeper societal     Contradictions and inequalities in   More just international trade,
inequities with alienation,      socio-economic and political         finance and political relations, etc.
exclusion and vulnerability)     systems at international, natioal
                                 and local levels
      ARE RESEARCHERS READY TO STUDY DEEPER DETERMINANTS?
                                GFHR FORUM 7 - Ravi Narayan,
                                         PHM
               PLENARY POVERTY AND HEALTH RESEARCH
          CHALLENGES FROM THE PERSPECTIVES OF THE POOR AND
                       SOCIAL EXCLUDED – VII
    PEOPLE’S CHARTER FOR HEALTH (PREAMBLE)
•   HEALTH IS A SOCIAL / ECONOMIC / POLITICAL ISSUE
•   FUNDAMENTAL HUMAN RIGHT
•   INEQUALITY, POVERTY, EXPLOITATION, VIOLENCE AND
    INJUSTICE ARE AT ROOTS OF ILL HEALTH
•   HEALTH FOR ALL MEANS :
     –   CHALLENGE POWERFUL INTERESTS
     –   OPPOSE GLOBALISATION
     –   DRASTICALLY CHANGE POLITICAL AND ECONOMIC PRIORITIES
•   CHARTER BUILDS ON :
     –   PERSPECTIVES OF VOICES RARELY HEARD
     –   ENCOURAGESD PEOPLE TO DEVELOP THEIR OWN SOLUTIONS
     –   HOLDS ACCOUNTABLE
          •   Local authorities
          •   National Governments
          •   International Organisations
          •   Corporations
                                   (PCH Challenge to Researchers)
                                                                    PHA 2000, Savar
                                  GFHR FORUM 7 - Ravi Narayan,
                                           PHM

				
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