09 March 2010

Justice, Inequality and Child Health

On International Women's Day, I chaired a session at an event on Equity and Child Survival organised by David Mepham and Save the Children UK. The meeting was to discuss how to accelerate reductions in under 5 child mortality rates. The premise of the meeting was that child health policy has neglected inequality. But what does "neglect inequality" really mean in a policy sense? This was the topic of the discussion. My takeaways were:

1. While we often present inequality in child health outcomes by income or asset groupings (for comparability across countries) these are not the inequalities that are the primary drivers of poor child health. Rather it is the structural drivers -- for example, gender, ethnicity, indigenous group, rural/urban, region, and religion -- that lead to power imbalances that perpetuate poor child health. The structural drivers are the ones to be tackled by policies.

2. But which policies? We cannot expect health policies alone to tackle structural drivers of inequalities. But we cannot allow them to ignore them either. So, how to organise the elements of a strategy to address inequities in child health? On one axis, put health policies and non-health policies. On the other axis, place policies that work within existing rules of the game and those that seek to transform the rules. Examples:

* Health policies working within the rules -- outreach to scheduled castes in India to increase the likelihood of newborns being breastfed within one hour of life
* Health policies transforming the rules--social audits of health facilities by intended beneficiaries
* Non-health policies working within the rules -- employment policies that are more compatible with child care
* Non-health policies transforming the rules -- more progressive tax regimes that fund universal access

These policies can also interact positively -- for example, rights based approaches are not health specific but can be used by health advocates to lobby for the abolition of user fees.

3. Does this go far enough? Many thought that this approach was still too instrumental--the reduction of inequality is treated simply a means to an end rather than something with intrinsic value. I agree with this view, and there was some consensus that we should be more focused on justice -- the key indicator of injustice being group differences in health outcomes by socially constructed group. Some of my IDS and ActionAid colleagues have written a terrific set of briefs on the interplay of redistribution (the allocation of resources between groups), recognition (the right to be recognised in and on one's own terms) and representation (the democratisation of information and agency) which gets to the heart of the new social justice agenda.

4. As many commentators noted, women's agency is vital to combating child health inequalities. Andrea Cornwall and Jenny Edwards have just released a new IDS Bulletin --well worth a read--on Negotiating Empowerment drawn from a DFID research programme hosted by IDS: "This IDS Bulletin draws out some of the dilemmas around women's empowerment: choices, negotiations, narratives and contexts of women's lived experience. It shows that empowerment is a complex process that requires more than the quick and easy solutions offered by development agencies (who need to have a deeper understanding of what makes change happen in women's lives). The issue draws on the work of an international network of researchers - the Research Programme Consortium Pathways of Women's Empowerment (‘Pathways') - and brings fresh empirical and conceptual insights to development academics and policy actors".

5. Finally, perhaps the biggest inequality is the attention given to inequality in recent years. Inequality is not a dirty word, but it is a slippery one. In a world where high carbon growth and weak financial regulation have generated huge negative externalities for those who can least bear them, it is not surprising that we hear more about justice and injustice. Is there something intrinsically more human and universal about the notion of "justice"? I'd like to hear from you on that.

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