Diasporas and global health
James Busumtwi-sam is the author of this post.
What is health? According to the 1946 WHO constitution it is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Today this definition is widely accepted, as is the notion that, in addition to its biomedical and technical elements, we should be concerned with the broader social determinants of health as shaped by the distribution of money, power and resources at global, national and local levels. This broadened understanding of and approach to health reflects increased awareness that health issues are affected by factors traditionally considered outside the health sector. Globalization and the proliferation of non-governmental actors and institutions (public and private) strongly influence the ability of national and local authorities to protect and promote public health, but profound health disparities exist across the globe. Situating health within the context of broader social determinants provides a better understanding of the sources of health inequities.
The absence of equity in the provision of health services is considered to be one of the major impediments to achieving positive health outcomes. The WHO’s 1998 World Health Report Health for All in the 21st Century, linked good health to the advancement of human rights, greater equity, and gender equality among other things. Social determinant of health generate health inequalities. An emphasis on health equity implies that need -- not income/wealth, power and privilege -- should be the major determinant of health-care access and ultimately of health outcomes. This notion was embodied in the 1978 Alma Ata Declaration. However, the profound disparities in health opportunities and outcomes across the world today, indicate quite a divergence between recognizing a ‘right to health’ in principle and in practice.
There is a stark relationship between poverty and poor health -- in countries classified as ‘least developed’ or ‘low income’, life expectancy is just 49 years, and one in ten children do not reach their first birthday. In high-income countries, by contrast, the average life expectancy is 77 years and the infant mortality rate is six per 1000 live births. There appears to be a ‘vicious cycle’ in the relationship between poverty and ill health -- poverty contributes to ill-health and ill-health leads to poverty. A recent report by the WHO and World Bank Dying for Change: Poor People’s Experience of Health and Ill-Health, notes that poverty creates ill-health because poor people tend to live in environments that make them sick, without decent shelter, clean water or adequate sanitation. It is within this context that the deprivations, exclusions and inequities associated with poverty and inequality have been highlighted as one of the biggest obstacles to promoting health globally.
The goal of achieving more equitable healthcare around the world faces serious challenges. As the WHO itself acknowledges, while there have been improvements in areas such as childhood immunization, there have been setbacks to providing equitable access to essential health care worldwide. Health system constraints including financial barriers and health worker shortages, combined with challenges such as the HIV epidemic, have hampered progress towards achieving health for all. In the 30 plus years since the Alma Ata Declaration, the equity and community-based (bottom-up) emphasis it espoused has been eroded in favour of ‘efficiency’ cost-utility (top-down) reforms based on neoliberal market economic principles (the so-called ‘Washington Consensus’ favouring privatization, deregulation, etc). User fees, cost recovery, private health insurance, and public–private partnership became the focus for healthcare service delivery. Overall, healthcare was seen in terms of economic benefits that improved health delivers (i.e., human capital for development), rather than as a consequence and fruit of development.
Aids warning sign as part of a USAID campaign with the Ghana police (photo: Shaheen Nanji)
More recently, the major MFIs and bilateral donors have made some modifications to this model. Some analysts talk of a ‘socially-inclusive’ neoliberalism (the so-called ‘post-Washington Consensus’) emerging at the end of the 1990s and into the new millennium. The MFIs and bilateral donors made ‘poverty reduction’ a cornerstone of their lending programs, and created new lending programs to accommodate higher pro-poor public expenditure in the South. It was within the context of this new agenda that the Millennium Development Goals (MDGs) were adopted in 2000.
The United Nations Millennium Declaration signed in September 2000 led to the adoption of the MDGs -- a set of eight goals and a number of numerical targets to be achieved by 2015 or earlier. At the heart of the MDGs is the recognition that health is central to the global agenda of reducing poverty as well as an important measure of human well-being. Health is the explicit focus of three of the eight goals, and health issues are acknowledged as central to the attainment of other key goals including eradicating extreme poverty and hunger, gender equality, and environmental sustainability.
The global financial and economic crisis that began in 2008, however, has had a negative impact on progress towards achieving the MDGs. By the end of 2010 – just five years to the target year of 2015 – the World Bank was reporting lack of progress in several key MDG indicators in poorer countries including health, nutrition, and poverty-reduction indicators. Maternal mortality has shown the least progress of all the health-related MDGs, the annual decline in child mortality is insufficient, and the global shortage of health workers reached 4.3 million in 2006. Small developing countries are disproportionally affected by emigration of health workers and donor funding for reproductive health on a per woman basis has fallen by over 50 per cent in 42 of the 49 least developed countries since the mid-1990s.
The contributions members of the diaspora make to global health can be situated within the context of debates over health equity and the challenges to realizing the health-related MDGs. In 2008 the WHO placed renewed emphasis on primary health care in its report Primary Health Care: Now More than Ever. Achieving this goal will require reducing exclusion and social disparities in health, reorganization of health services around people’s needs and expectations, integration of health into all other sectors, pursuing collaborative models of policy dialogue and increasing stakeholder participation. In addressing diaspora contributions to improving global health we might ask:
- In what ways can the diaspora help achieve these goals?
- What are the main areas in which the diaspora have a comparative advantage or unique opportunity to engage with communities in their places of origin/attachment to help in the ‘development’ process, and how can they organize to increase the impact they will have (conversely, what are the constraints they face)?
- What are the opportunities/insights for successive generations to participate in the development process in their places of origin/attachment?
- Do subsequent diasporic generations lose some of the socio-cultural context that might provide them greater or lesser insight into their places of origin/attachment? Is the perspective they bring significantly different and if so, how?
- How do diaspora bring about positive ‘systemic’ changes in their places of origin/attachment?
- How might the diaspora accelerate more substantive or fundamental changes than are associated with small, discrete projects such as improving sanitation and access to safe drinking water in a single village?
- What opportunities are there for diaspora to engage in advocacy work, knowledge creation, and capacity building? Are there any positive changes that diasporic researchers bring about through their studies and proposals?
- In what ways are these experiences and interchanges transforming health practices and understandings in the North? (i.e., what is the looping effect?)
James Busumtwi-Sam is Associate Professor of Political Science and (acting) Development & Sustainability program at Simon Fraser University. He will participate in the Engaging Diasporas in Development project’s March 16 dialogue “Improving Global Health." Those interested in participated can register here.