Addressing Health Inequalities, Social Exclusion, Conditionality, and Community Empowerment

1. SEKN Addressing health inequalities social exclusion, conditionality and community empowerment. Jennie Popay Montreal November 2008

2. About the presentation SEKN • Tell you a little about the WHO Social Exclusion Knowledge Network (SEKN • Consider two key ‘problems’ facing public health policy and practice & relationship between them • Health inequalities • Social exclusion • Consider two prominent solutions being tried to address these problems: • Conditional programmes • Community empowerment • Consider mechanisms linking these problems and solutions in particular the notion of community control

3. A short history of the SEKN SEKN • One of nine knowledge networks working with the WHO Commission on the social determinants of health (CSDH) • Began work formally late 2006 • Final report submitted May 2008 • Not a lot of time and not a lot of money but a great deal of commitment! • All CSDH reports available on: http://www.who.int/social_determinants/

4. SEKN: structure & global reach Global: geographic diversity within regions Europe:Lancaster, UK Jennie Popay South East Asia: ICCD,RB & BRAC Co-or: Heidi Johnston South American: Colombia. National &Javeriana Universities Co-ordinator: Mario Alvarez Southern America: Fiocruz, Brazil: Co-ordinator Sarah Escorel Southern Africa hub: Human Sciences Research Council; Pretoria & Mozambigue Co-ordinator - Laetitia Rispel Other members/links SEKN

5. What did we do? • Considered different meanings attached to social exclusion around the world • Explored link between social exclusion and health inequities • Appraising policies and actions that had potential to address social exclusion • Produced a data base of policies/actions not yet appraised. • Built sustainable global knowledge network continuing into the future SEKN

6. so what meanings are attached to: SEKN • health inequalities • social exclusion

7. Residual: the poorest groups are the problem or Gap: the difference between the poorest groups and the rest is the problem or Gradient: inequalities right across the social spectrum are the problem What are health inequalities? Residual or Gap approaches dominant public health policy and practice globally

8. Victim blaming & paternalism: ‘risky’ lifestyles & lack of motivation and knowledge; health illiteracy Psychosocial pathways: material inequalities reduce social cohesion; rot the fabric of societies Social Determinants: focus on impact of material, social, psychological, political and cultural context of people’s lives – life worlds not life styles What causes health inequalities ? Behaviour change and psychosocial approach dominate public health policy and practice globally

9. what meanings are attached to: SEKN • social exclusion

10. What is social exclusion? • Concept developed in France in 1960’s to speak about people excluded from labour market and welfare rights associated with it (Rene Lenoir) • Concept quickly driven across European Union and then out globally by ILO, World Bank and donors • Some resistance (e.g. Sub Saharan Africa, Canada?) where other concepts have greater salience: • Human rights; • Poverty and basic needs • Income inequalities • Social cohesion and social capital • Sustainable development • But concept of social exclusion now shapes action on socio-economic inequalities/poverty in many countries • So how is it being defined – two broad approaches

11. 1. Shopping basket approach A state experienced by severely disadvantaged groups e.g. People living in informal settlements, dahits, indigenous people, homeless, dis-functional families, etc Excluded from: secure, employment; decent income; self determination,, credit, land; healthcare housing; education, citizenship and legal equality; participation; cultural recognition’ ........etc

12. The shopping basket approach has... Advantages.. Disadvantages... Makes poverty less visible Another stigmatising label Problem seen as dichotomy – included or excluded –gap not gradient Doesn’t ‘work’ when most are poor e.g. Bangladesh • Moves beyond lack of money as the poverty problem • To recognise wider social psychological, cultural & political impacts of poverty • Re-energised action for greater equity

13. SEKN But most important disadvantage of shopping basket approach It describes problems - doesn’t identify causes

14. 2. Exclusionary processes (not excluded states) that.. • Drive socio-economic and health inequalities • Originate in unequal power relationships operating across • different dimensions - economic, political, social and cultural • different levels: individual, households, country , global regions. • Create continuum of inclusion/exclusion – gradient not gap • Gradient characterised by unequal and unjust distributions of resources, capabilities & rights Approach to the problem encompasses complexity e.g. groups may occupy different positions on different dimensions. SEKN

15. Exclusionary processes and health inequalities State Civil Society InternationalAgencies Social capabilities Private enterprise Economic capabilities Religious organisations inclusion Political capabilities exclusion Global capital markets Labour movement Cultural capabilities households individuals Social positions & social stratification at different levels: individual, group, area, nation, international ‘community’ Health Inequities

16. So what about solutions? • Conditionality SEKN

17. What is conditionality ? • Cash/service transfers provided on certain conditions • Always been with us e.g. Means tested benefits for poor people • But increasing use of ‘behavioural conditionality’ • What is behavioural conditionality? • Cash/service transfers only given in return for ‘good’ behaviour • ‘Good behaviour’ defined by middle class professionals SEKN

18. Does behavioural conditionality have added benefits? Cash transfers conditional on clinic &/or school attendance • Brazil (Bolsa Familia); Chile (Solidario ); Mexico (Progresso);): • Reduction in child poverty • Improved nutrition • Increased school registration/attendance • Increased clinic attendance BUT • uptake variable e.g. lowest in lowest income groups in Brazil • High cost of administration Unconditional transfers • Child benefit: UK, South Africa • High uptake • Reduction in child poverty • Women spend money on food, children’s clothes & school fees • Free Primary School education in Botswana • attendance rates 84% • gender parity at primary level

19. So what about solutions? • Community empowerment SEKN

20. What is community empowerment? Many definitions in UK policy suggest confusion about purpose e.g. • ‘Building people’s skills, knowledge, abilitiesand confidence to take action and play leading roles in improving services • ‘empoweringcitizens to express views on how needs are met’. • ‘working with local people to strengthen accountability’ • ‘bringing local people into the service delivery system’ • ‘putting active citizens at the heart of tackling social problems’

21. Current practice in CE is......... • Sometimes good: • Opens up space for social transformation – well resourced community control over agenda setting and design, delivery and evaluation of interventions/services • Often bad: • Inadequately resourced; legitimises reduced role for public services and privatisation of welfare • And can be ugly: • Damaging lives and health of community activists

22. What about the change mechanisms? Behavioural Conditionality • Assumes poor people are irresponsible • Prioritises economic incentives for responsible behaviour • ‘Naming and shaming’ – stigma as informal social control • Coercion – social engineering These mechanisms can change behaviour but may increase exclusionary processes via stigma and undermine control’ Community empowerment • Increased ‘sense of control’ will have direct health benefits • Empowerment will strengthen social networks increase cohesion and inclusion • Access to people’s wisdom of experience – will lead to more appropriate interventions/services ‘owned’, valued and used by communities Increasing sense of control can have direct impact on health and also indirect through uptake of effective services

23. The health potential of community control • Study of Indigenous suicide in British Columbia (Chandler et al 2003) • Significantly elevated suicide rates (overall 5 times greater across the province between 1987-1992) • But not uniformly distributed across 1st Nation groups: • So, aboriginality per se is not a risk factor. • ‘Cultural continuity’ explained different risks • Measures of cultural continuity reflect degree of ‘community control’ • history and success of land claims; • self government; • control of services; • Dedicated cultural facilities Personal persistence, identity development and suicide, Chandler, Lalonde, Sokol, Hallett, Monogr.Soc.Res.Child.Dev. 2003:68(2)

24. Decreasing suicide rates with increasing community ‘control’

25. Conclusions • Increased control at individual and collective level can reverse exclusionary processes and reduce health inequalities • Programmes that use behavioural conditions drive exclusionary processes via stigma and undermine control • Genuine well resourced community empowerment can increase community control of decisions that affect their lives and improve the design, delivery and utilisation of services/interventions • Public health practitioners should advocate for and implement interventions that promote authentic community control • But authentic community control: • Challenges dominance of professional practice & knowledge • Reveals the political nature of public health practice