Questions of health and inequality in Southern Africa: the case of Mozambique Bridget O’Laughlin IESE April 2011

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.

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

Under-five mortality rate/ rural urban Rural:urban ratio Source: Equity Watch 2010 p. 14

Under-five mortality rate/1000 by wealth quintile grouping lowest nd rd th highest rich:poor ratio Source: Equity Watch 2010 p. 14

Under 5 mortality rate (per 1000) by province 2010 Source: Equity Watch 2010, p. 17

% Births attended by skilled personnel Rural Urban Urban:rural ratio Source: Equity Watch 2010 p. 18

% Births attended by skilled personnel by wealth quintile grouping lowest nd rd th highest rich:poor ratio Source: Equity Watch 2010 p. 18

Percentage of users reporting access to alternative health care providers by residence (2003) ProviderRuralUrban Community health post Hospital Other health centre or post Private for profit clinic Nurse or doctor working from home Outside services from facility staff Religious organization or NGO Traditional medical practitioner Pharmacy outside facility Market (that sells medicine) Source: Adapted from Lindelow et al 2004, Table 53, p. 82

Inequality in access to safe water and sanitation Equity Watch 2010 p. 31

Regional inequalities: improved sanitation and safe water Source: Equity Watch 2010, p. 31

Rose’s 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

Mosley & Chen Critique of approaches to Mortality Source: Mosley & Chen

Mosley & Chen Alternative

Modelling AIDS Mortality Socio-economic determinants Proximate determinants (bio-medical factors affecting): exposure to HIV infection by HIV immune system collapse AIDS mortality Indirect Influence on morbidity and mortality Direct Influence on morbidity and mortality ( Cost-efficient policy focus)

Cordell & Piché (adapted): demographic regimes as outcomes Political economyHealth environment Direct causes of death Demographic regime State policies and practices Parasitic diseasefertility Civil society organisations policies and practices Infectious diseasemortality Social ClassDegenerative disease migration Gender relationsCongenital disease Illness treatment: personnel, services, supplies suicide Violence accidents

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

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?

Southern Africa

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

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

Ranges of country values Minimum31 Median2821 Maximum165 WHO region African Region9885 Region of the Americas2215 South-East Asia Region6348 European Region1812 Eastern Mediterranean Region6657 Western Pacific Region2818 Income group Low income8876 Lower middle income5544 Upper middle income2619 High income76 Global5445 Mozambique12490 South Africa5248 MDG 4 Under-five mortality rate (probability of dying by age 5 per 1000 live births)