Alicia Ely Yamin, Director, Program on Health Rights of Women and Children, discusses concepts of equity and equality from a public health perspective unique to her twenty plus years of work in academia and activism where she has been at the forefront of the agenda for economic and social rights, and health and human rights fields. Ms. Yamin is a Lecturer of Global Health and Director of the Program on Health Rights of Women and Children at the François-Xavier Bagnoud Center for Health and Human Rights at Harvard University.
Interview conducted in March 2014
Q. What do you think about the current concepts of equity and equality? What is your perspective on these concepts, and how would you describe them? How do you perceive them being employed by organizations and others?
A: In the health field the concept of equity is much more prevalent than the concept of equality. In human rights, we talk about two different kinds of equality linked to norms or non-discrimination. We talk about formal equality in the context of treating everybody who is similarly situated the same. This is very much linked to universalizing entitlement programs for example. And then there’s substantive equality, which is making sure people who are not necessarily situated in the same way, effectively get equal enjoyment of their rights. This is very important for people in marginalized populations, such as disabled children, girls, or ethnic, racial, and religious minorities. The way in which these concepts are balanced and applied is very relevant for achieving Universal Health Coverage (UHC), for example, including what sorts of special entitlements or prioritization might be placed on children.
The concept of equity in health is very complex. There are an array of different definitions, but what it doesn’t simply mean is just attention to income differentials and disparities. As opposed to other domains, health can also have other kinds of inequities. There are trade-offs to providing the largest aggregate benefits for a population and treating fewer people who have very serious diseases. This has come up in health rights litigation in certain middle-income countries in Latin America, for example in conflicts between awarding one child with a very serious disease access to a costly medication or even to treatment abroad, while the State has yet to provide all children with access to basic sanitation and nutrition. There are rarely fascile answers to these conflicts but my point is that there are different dimensions of equity in health in particular that may not affect other kinds of social rights for children.
Q: Its complexity then results from the many possible definitions, right?
A: Indeed, there are many different definitions of equity in health. Most incorporate cost effectiveness into equity and while some human rights scholars eschew cost-effectiveness I believe this approach does have a place in priority-setting because if you are spending money on interventions that are not cost effective, you are essentially taking money away from things that could potentially yield greater benefits to a larger population. There is an ethical dimension to cost-effectiveness.
There are also issues of clinical effectiveness in the context of interventions, and then there are also issues related to the potential financial catastrophe faced by people who are affected by certain conditions. And of course there are issues of social equity, which is related to the social class, race, ethnicity, status as a marginalized group, etc of the population being considered. So, in short, there are a lot of different dimensions and questions to answer within the concept of equity in health.
Q: How would you describe the main causes of increasing inequities that we observe today in the world, and also at a local level?
A: The principal underlying cause is the collective failure to think beyond the hegemonic grasp of neoliberalism. We see the austerity policies across Europe, the growing income differentials in the United States, and certainly in Latin America and in South Africa. The more affluent take control of political processes and thus exclude the voice of the majority of the population. I think frankly national and international institutions accept certain givens about the way economies need to be arranged, about the role of the state, about the role of the private sector. We even see this at the global level; now, in terms of the Post-2015 Agenda, there is such an emphasis on the role of the private, corporate sector in the future of the development agenda. Despite the newfound emphasis on “governance” at the same time we are turning to these largely unaccountable institutions.
Further, what is considered to be an externality from the perspective of a corporation as it relates to pollution, labor conditions, land grabs, or water usage is fundamental to a social order that enables people, including children, to enjoy their human rights and enjoy wellbeing.
Q: Based on your research, what would be the key recommendations you would like to share with policy makers and practitioners that would promote more equity and put a dent on inequities?
A: I do a lot of different kinds of research. For example, I have led a four-country study across different countries in Africa (Ethiopia, Tanzania, Malwai, South Africa) based on combined quantitative and qualitative research methodologies. One of the interesting findings we have gathered from this project is how dramatically affected children are when women die in pregnancy or childbirth. Not just the infant children but actually the children who were alive previously as well. This kind of research leads to questions about concepts of equity and priority setting. That is, there are both immediate constituent effects of maternal deaths on women, of failure to prioritize reproductive health services. But there are also these consequential effects which should be taken into account in countries with limited resources. This is related to addressing inequities because the women who die maternal deaths and the kids who suffer and sometimes die are invariably among the most marginalized, poorest populations. We must then ask, how we get governments in countries with very high maternal mortality rates (most of which are highly dependent on aid) to prioritize reproductive health interventions to mitigate the already existing disadvantage they face in society? We hope the research can provide an evidence base to advocate for changing policy makers’ minds about what would reduce inequities over time.
I also do a lot of policy research at the international level–on Post-2015 and otherwise–that show the way in which global aid and trade rules are set, the way in which revenues are collected in much of the global South, and the way revenues are avoided by many transnational corporations. The way in which this international framework is set, I find, has an enormous effect on equity within and between countries. We saw this in the last Bali meeting where they couldn’t come to an agreement because of food subsidies that India stuck to. These issues of not allowing governments to subside food for their vulnerable populations, whether in humanitarian crises or otherwise, have enormous impacts on the way wellbeing and rights are distributed. And of course nutritional policies have an especially dramatic impact on children.
Q: What do you think are some of the best practices in terms of policies and programs that you have seen to guarantee better well-being for children?
A: Unfortunately, I have not found a lot of best policies or practices in Sub-Saharan Africa over the last few years. In public health, there are a lot of studies on how greater income equality across society actually leads to better health outcomes—and not just among the worst off but also among the best off. Conversely, there seems to be some correlation between great income inequality and other poor social issues, such as crime, insecurity, and other stress related matters – all of which is clearly evident in South Africa, for example.
The countries in which I have been doing most of my recent research are very poor countries. They don’t tend to control a lot of these upstream issues. In Tanzania and Ethiopia, for example, they could do a lot better in terms of allocating their resources. They can still do a lot better in preventing corruption because there is tremendous inequity in the way the resources are allocated. But there is also the issue of fostering more governmental accountability to their citizens instead of the donors. In the field I work in –reproductive and maternal health– these policies and the funding are generally set by donors, and with the ministry of finance, not even the ministry of health, behind closed doors. I wouldn’t call it a best practice in any of these countries I work in.
Q: You mention social accountability as also a way of making sure that resources are well allocated, can you provide an example of a case in which this was successfully done?
A: I can think of the Fundar example in Mexico. And actually, there have been some examples in South Africa of budget monitoring that have been quite successful. In Tanzania, Sikika also provides a good example. Sikika focuses on health advocacy, and has been working on health and budget issues since 2005. Sikika’s overall vision is a Tanzania where healthy and responsible citizens enjoy equitable, affordable, and quality health services as their basic right. In countries such as Uganda they are also starting to do some budget monitoring. The International Budget Project (IBP) had a partnership initiative there, funded by the Gates Foundation and Open Society, where for several years they partnered with local groups and gave them capacity building to monitor budgets, revenues, and to look not just at allocation but also implementation of budgets.
I was also involved in Peru with what has now become a model of social accountability, where community health promoters are accompanying women on antenatal care visits and delivery care, and monitoring their health facilities and channeling complaints through the Human Rights Ombudsman’s Office. This is an example of best practices, or good practices, I would say. It has been cited by the Independent Expert Review Groups (IERG) created under the Commission on Information and Accountability for Women’s and Children’s Health, and it was also cited as an example in the World Bank’s last report on investing in reproductive health (2013).
Q: What are good methodologies or practices to capture and monitor equity issues around children or adolescents in your area of research?
A: I work on health from a rights perspective. As a result, I would not just look at outcome indicators often used in health, such as percentage of children who are stunted or undernourished, etc. Equity also requires analysis of the legal and policy frameworks to ensure non-discrimination and the like and also budget formulation and allocation.
A rights-based approach to measuring equity often requires multiple methods and sources of information, both quantitative and qualitative. Ethnographic research and mapping demographic information onto information about health indicators or outcomes can be very useful, as can budgetary information.
Alicia Ely Yamin, JD MPH is a Lecturer on Global Health and Director of the Program on Health Rights of Women and Children at the François-Xavier Bagnoud Center for Health and Human Rights at Harvard University. Her work over the last twenty years has spanned academia and activism, where she has been at the forefront of the economic and social rights and health and human rights fields. Yamin has published dozens of scholarly articles and various books relating to health and human rights, in both English and Spanish, and has received multiple distinctions in respect of her work on maternal health and sexual and reproductive health and rights, in particular. She frequently writes articles and op-eds about global development processes, in relation to sexual and reproductive health. She recently edited, together with Andy Sumner and Malcolm Langford, The MDGs and Human Rights: Past, Present and Future (Cambridge U Press, 2013). Yamin provided expert input into the UN Secretary General’s Global Strategy on Women’s and Children’s Health (2010), and served on the Advisory Panel for the 2011 Partnership for Maternal Newborn and Child Health Commitments Report as well as the WHO Steering Group relating to Evidence of Impact of Rights-Based Approaches to Women’s and Children’s Health. She is also a member of the WHO-led initiative on equity in achieving universal health care. Yamin is Chair of the Board of the Center for Economic and Social Rights (CESR) and was elected to represent CESR on the Executive Committee of the Beyond 2015 Campaign, the largest civil society coalition advocating for an inclusive and pro-equity future development agenda.