At the same time, this mandate of decentralization promotes an opportunity for community participation and for revolutions in task-shifting.  As South Africa prepares to rollout a public health program that puts ARV prescription in the hands of doctors rather than nurses, I have seen directly how shifting responsibilities down can free up human resources and increase access to care and medication. 

 I think the key to strengthing health and development in the field is striking a balance between decentralized policies and health care services and regulatory structures that ensure implementation and quality of care.  Thus, perhaps the mandate should be not to decentralize powers and services down but to spread powers and services across national and local levels.

The economic growth-oriented reforms enacted by the Chinese government, such as the Chinese State Council’s promotion of privatization of health services delivery in the early 1980s, have had profound impacts on access to and use of quality maternal health services (QMHS) in the field.  Specifically, these policies have exacerbated barriers of access to and use of QMHS among rural women.

With the 1980s privatization reforms of health service delivery in China, the Cooperative Medical System (CMS) in rural China disintegrated.  This created barriers of access to and use of maternal health care among rural populations through its affect on out-of-pocket costs.

Growth-oriented reforms drastically increased out-of-pocket costs for health care throughout China, influencing both access to and use of QMHS in China.  Between 1978 and 2002, the government’s share of total national healthcare spending decreased from 32% to 15% while out-of-pocket costs increased from 20% to 58% of total national healthcare spending. Rising costs created especially strong barriers to accessing and using health services in rural areas, where the disintegration of the CMS left rural residents without a risk-pooling mechanism.  Indeed, a 2003 study found that 39% of rural residents avoid seeing doctors because they are unable to afford medical treatment.

Such financial barriers to care directly affect uptake of institutional delivery among rural residents.  A retrospective household survey conducted in 1995 in three provinces in central China found a strong negative association between utilization of institutional delivery services and out-of-pocket costs in rural areas.

I will continue to assess financial barriers to care as I make the move to South Africa in a few days!!

Sources:

Project Team of the Development Research Center of the state council of China, 2005.

Ma S, Sood N. RAND Center for Asia Pacific Policy. Comparison of the health systems in China and India.

Bogg, L, Wank K, Diwan V. Chinese maternal health for adjustment: claim for life. Repro Health Matters. 2002; 10 (20):95-107.

One theme I have learned is that the existence of a policy or program is not necessarily causally related to MMR.  Instead, an institutional environment—which incorporates not only programs themselves but also community participation and the efficient administration of programs—impacts maternal mortality.
For example, the Integrated Child Development Scheme (ICDS) in rural Karnataka targets expectant and lactating mothers and, by mandate, provides health check-ups, supplementary nutrition, immunization against tetanus, and nutrition/health education (10).  On the ground in the rural Kaiwara district of Karnataka, however, a lack of administrative capacity and community mobilization disrupts a neat causal arrow between the ICDS and reduced MMR.  While the ICDS stipulates that there should be one worker (called an Anganwadi worker) per 1,000 population, the Anganwadi worker in the Santhekallihalli area of Kaiwara serves closer to 3,000.  In addition, informal conversations with women in Santhekallihalli illustrated the ways in which community attitudes/awareness mediate the causal link between maternal health programs and maternal mortality.  For example, of 11 women residing in Santhekallihalli that were asked whether they knew about health education activities held at the Anganwadi center, only 3 knew about them.  This suggests that Anganwadi activities are not well known within the community, much less seen as a community-owned endeavor. Not only a program but also its funding, administrative considerations, and acceptance within the community can influence MMR in rural Karnataka.

I’ll make my post for the next week or two a reflection on Jordan’s post. I completely agree that “If capacity is built in these countries, then the countries of the developing world would be better equipped to handle the needs of their citizens and could be more responsive to social movements through participatory democracy.”

However, my case study on Maternal and Child Health in rural India this past week has shown me that this paradigm may have to work in the reverse. For instance, the public health care delivery system in the Karnataka state of India is well-organized, well-designed, and even elegant. There are health workers for every 1,000 villages, a sub-health post to serve every 5,000, and a Primary Health Center to serve a population of 30,000. However, the gap between this seemingly effective structure and its implementation suggests that cultural and social norms may be a precursor to the effectiveness of health care delivery systems. For instance, I spoke to a women who did not give birth at the Primary Health Center (even though it is free and the government even reimburses transport and other costs) because of mistrust of medical institutions. So, we need aresponsive structure, but this structure must be built upon community ownership and acceptance.

In my last post, I addressed ideas of top-down and bottom-up approaches to development. After a site visit to Hlokomela, a trust that provides ARVs, peer-education and a comprehensive set of health services to migrant workers in the area of Bushbuckridge in South Africa, it has started to become more clear to me that the most successful organizations tie in both of these approaches (combined with a human rights paradigm) to provide for the people who use their services. In successful organizations, there is face-to-face interaction between community health workers, home-based care administrators, or peer educators and the person receiving the service. But oftentimes, there’s also engagement with policy, or even development of models to replicate successful methods of care. This can attack the sources of illness at both levels, providing prevention and treatment services at an individual and community level, as well as a policy-oriented approach on national and international level.

We meant to address issues of voluntourism this week (the idea that people pay money to do predetermined volunteer work in an area away from their own home), but there should probably be a differentiation between types of voluntourism. A relief worker in Haiti has a different role than students paying thousands of dollars to play with orphans in Africa. Largely, people with a good amount of knowledge should be able to determine how sustainable the project they are working on will be, but in general, projects where the people being affected by the services aren’t a part of the development process wouldn’t be as sustainable as those projects where community members are involved in the development process that will affect them directly.

First let me give a brief introduction because this is my first post. My name is Francis Gonzales and I’m a Junior Development Studies concentrator at Brown. I’ve taken many of the same classes as Jordan and Liz and was excited to develop this class with them as we studied abroad. The IHP program has been a great supplement to the lessons that I’ve learned in classes like The Burden of Disease in Developing Countries and our Development Studies Seminar.

As a part of our study abroad curriculum we visited several NGOs in Washington DC as well as South Africa. In Washington DC we heard from an organization called Metro Teen AIDS http://www.metroteenaids.org/. A handful of teenage girls who served as peer educators in their community came and answered our questions. They spoke about their initial embarassment discussing issues of sexual health and HIV/AIDS with their peers but eventually found the experience empowering. Washington DC’s HIV/AIDS statistics are higher than those in some developing countries and the work that Metro Teen AIDS is doing is quite important. The peer educators are an essential part of their programs because they are the ones who hand out condoms in their high schools and they can relate to their classmates in a way that health professionals simply can’t.

In South Africa we’ve visited an herbalist, a daycare center, and the Apartheid Museum in Johannesburg among other things. The site visit that I found most interesting however was to an organization called Hlokomela http://www.htt.org.za/ in the rural northwest of SA. Hlokomela works with migrant farmworkers in the area and provides several different programs that seek to increase awareness and change behaviors related to HIV/AIDS. They train and mentor farm workers to serve as caregivers on their particular farms. The particular project that I found most interesting included efforts to sensitize, train, and mentor male role models to address issues such as gender based violence, transactional sex, and poor health-seeking behaviors in men. I was glad to see this emphasis on mens health because it seems that womens health is always talked about in my classes.

The use of peer educators is truly a global phenomenon.

As a participant in the International Honors Program track that started in Washington, D.C., we spent much of our time acquainting ourselves with the nation’s capitol and visting various NGOs and legislators. I had to chance to visit with Development Alternatives, Incorporated, a large development consulting firm that contracts for bids from U.S. government projects. On the same day, I also had the chance to meet with emPOWER, a community organizing group that works with community members to choose issues that they find personally value and then help community members become activists for themselves.

What I saw was a dichotomy between top-down and bottom-up/grassroots approaches to development and health. One approach leveraged the power and influence of the US government to acheive region-wide results in other countries, while the other used personal issues to fire up and empower community members to fight for their rights. And this is what I’ve found in development – it’s top-down or bottom-up. An in-between is hard to find.

Amartya Sen came up in quite a few of our classroom discussions, and the concept as “development as freedom” through particapatory democracy certainly seems to fit grassroots organizations better. But if many people in the development community prescribe to Sen’s ideals of emanciaption from poverty through local movements (similar to the ideas of Arturo Escobar), then it becomes problematic that the large amount of development funding goes to large consulting firms that are still answerable to profit and efficiency as bottom lines. Granted, many of these large consulting firms act as middle-men, then contracting their services out to smaller organizations.

With large development organizations, there’s a missing link between democracy and large development organizations, oftentimes because local and national governments of the countries they work in are bypassed. If capacity is built in these countries, then the countries of the developing world would be better equipped to handle the needs of their citizens and could be more responsive to social movements through participatory democracy.

-Jordan