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Questions of health and inequality in Southern Africa: the case of Mozambique

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Title: Questions of health and inequality in Southern Africa: the case of Mozambique


1
Questions of health and inequality in Southern
Africa the case of Mozambique
  • Bridget OLaughlin
  • IESE April 2011

2
Argument
  • 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.

3
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 subsistence-producing
    family can/must take care of itself?
  • The causes of Sick Populations 3 examples
  • Health and the space of governance

4
Under-five mortality rate/1000
  • 1997 2008
  • rural 270 162
  • urban 166 135
  • Ruralurban ratio 1.6 1.2

Source Equity Watch 2010 p. 14
5
Under-five mortality rate/1000 by wealth quintile
grouping
  • 2003 2008
  • lowest 196.2 171.9
  • 2nd 199.8 169.2
  • 3rd 203.3 169.1
  • 4th 154.6 136
  • highest 108.1 109.9
  • richpoor ratio 1.8 1.6

Source Equity Watch 2010 p. 14
6
Under 5 mortality rate (per 1000) by province 2010
Source Equity Watch 2010, p. 17
7
Births attended by skilled personnel
  • 2003 2008
  • Rural 34.1 46
  • Urban 80.7 78.7
  • Urbanrural ratio 2.4 1.7

Source Equity Watch 2010 p. 18
8
Births attended by skilled personnel by wealth
quintile grouping
  • 2003 2008
  • lowest 25 36.1
  • 2nd 33 45.0
  • 3rd 68 52.9
  • 4th 89 66.2
  • highest 89 88.3
  • richpoor ratio 3.6 2.5

Source Equity Watch 2010 p. 18
9
Source Adapted from Lindelow et al 2004, Table
53, p. 82
Percentage of users reporting access to alternative health care providers by residence (2003) Percentage of users reporting access to alternative health care providers by residence (2003) Percentage of users reporting access to alternative health care providers by residence (2003)
Provider Rural Urban
Community health post 3.3 1.9
Hospital 18.6 70.5
Other health centre or post 34.7 67.7
Private for profit clinic 0.4 10.4
Nurse or doctor working from home 0.8 2.9
Outside services from facility staff 0.0 1.7
Religious organization or NGO 20.0 14.5
Traditional medical practitioner 76.4 51.2
Pharmacy outside facility 0.3 38.5
Market (that sells medicine) 5.0 12.2
10
Inequality in access to safe water and sanitation
Equity Watch 2010 p. 31
11
Regional inequalities improved sanitation and
safe water
Source Equity Watch 2010, p. 31
12
Roses distinction
  • 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

13
Mosley Chen Critique of approaches to Mortality
Source Mosley Chen
14
Mosley Chen Alternative
15
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
16
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
17
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
18
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?

19
Southern Africa
20
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

21
Health and the space of governance
  • 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

22
MDG 4 Under-five mortality rate (probability of
dying by age 5 per 1000 live births)
2000 2008
Ranges of country values Ranges of country values  
Minimum 3 1
Median 28 21
Maximum 165 165
WHO region    
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
Income group    
Low income 88 76
Lower middle income 55 44
Upper middle income 26 19
High income 7 6

Global 54 45

Mozambique 124 90
South Africa 52 48
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