Power discussion is central to health equity

Reading the article  that was was co-authored by the ambassador of Belgium  Rudi Veestraeten, and Prof. Dr. Rhoda Wanyenze, the Dean, Makerere School of Public Health the Daily Monitor of April 7, about health equity, was refreshing. 

My rejoinder is that the two dignitaries could have been clearer by not mixing the pursuit of health with healthcare. And this is the “problematic” prevailing in health equity debates, especially when a non-committal term such as “disparity” is used to ascribe inequities. Critics have identified the persistence of positivist science as central to this aberration such that we must be deliberate to discern health from healthcare in every conversation.

Health inequity consideration arises from social and economic conditions, most of which are unfair but also avoidable. Health care pertains to downstream curative approaches which are narrow in scope. Health is the general wellbeing, and it depends on social, economic, and environmental determinants (social determinants of health), whose resource distribution is moderated through public policies. How these resources are produced and distributed across the population defines inequities in health. 

For health equity to materialise, society should question imbalances in the distribution of power and privileges in a way that paves way for equity public policy - itself a social determinant of health. Rudolf Virchow demonstrated this correlation during the 1847-8 Typhus epidemic in upper Silesia. Rudolf developed the term “social medicine” to reflect the need for social, economic, and cultural factors that he deemed central in the typhus etiology and identified the lack of participatory voices (alienation from politics and democracy) as contradicting local efforts to contain the outbreak. 

Virchow’s experience translates in the Uganda scene by the increasing socio-political disempowerment of Ugandans through the rampantly fraudulent and violent socio-political processes. The chronic and pervasive corruption and violence against the people disempower citizens from holding their state managers accountable for inequities in their health experiences. When people feel that they have no voice in how their society should be managed, their input in the public policy processes diminishes to their own detriment. 

Today, very few Ugandans can seek accountability for failures of government to deliver services relevant to health. Take, for instance, we all know the importance of education and early childhood development, accessible healthcare services, employment and working conditions, infrastructure and built environment, etc., have on the health of every community. These services are often delivered within a community, requiring community input in ensuring that they are made accessible and culturally relevant. Without the political clout and community voice, the government has felt no obligation to elevate these services to an acceptable level rather than divert service delivery to the private sector. Social services are constantly on the decline among the poor majority indicating a loophole in the policy processes, but also a strong favour for the market orientation.

Most revealing is the new concept of equity in this aegis of neoliberalism. The government is steering Uganda into the money nexus, and yet many Ugandans are not prepared. In effect, commodification has augmenting exclusion in understanding the dynamics of the money economy and its distribution, thus, equity now means the ability to pay from out-of-pocket to gain access. 

Moreover, monetary income is the most important element in the market economy. In the Ugandan context though, the market orientation is exclusive of the majority with soaring unemployment across the population affecting the social and family context. That experience further strains social relations as everyone depends on the other. This is made worse because liberalism thrives on individualism which is literally tearing families apart.

Lastly, health equity has been redefined and Ugandans should see it for that. The true meaning of health equity is that individuals, and not the government, should cater to their needs using out-of-pocket resources, which is driving families to catastrophes. The idea that healthcare is the solution to poor health is untrue. We must escalate investment in a socio-politically empowered community and in their public health systems. 

Mr Komakech specialises in Health Policy and Equity research with a focus on Global Health.