Food for a targeter's thought (1)
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EQUITY AND SOCIAL SECURITY
The expansion of social security schemes linked to health and nutri-
tion benefits is, in a way, a variant of the health insurance ap-
proach. It can, therefore, be considered a partial proxy to introduc-
ing a fairer tax system. This, because it is an approach for salaried
workers covered under the social security system only. In it, they --
as well as the employers -- pay for social benefits, including health
benefits. The scheme thus also leaves the peasantry, the workers in
the informal sector and the indigent (i.e. most of the poor) largely
beyond reach. Ergo, this strategy is also, at best, equity neutral,
but most probably equity detrimental. We are, therefore, better-off
left to lobby for more deliberate direct measures related to greater
fairness in the tax system.
SO WHERE TO GO FROM HERE?
Because overall poverty reduction is a theme getting growing atten-
tion these days (the upcoming World Development Report 2001 will
again be devoted to poverty), health and nutrition professionals have
a golden opportunity to work harder to influence overall development
strategies towards equity in health and nutrition. We should not
'leave it up to the Joneses' again and miss this unique opportunity.
The sense of urgency is heightened when we accept the fact that the
health/nutrition sector cannot, by its technical actions alone, make
significant long-lasting improvements in the health/nutrition condi-
tion of the poor.
Breaking down health and nutrition data by income quintiles, as pro-
posed by the WB, is a welcome first step to consolidate a credible
international database that can be used to track equity issues in
health and nutrition. Results from the analysis of these data should
be published annually in a publication of the type and stature of
UNICEF's "The Progress of Nations" or UNDP's "World Development Re-
port" where countries are ranked according to their respective per-
formance. The publication would further analyze existing gaps and
targets would be set for individual countries' improvements for the
following year.
But actually using these data to tackle the inequities at national,
sub-national and especially the local level is where the real chal-
lenge lies. Donor agencies will have to more forcefully advocate for
equity-promoting, participatory, bottom-centered interventions, as
well as being more responsive to low income countries' government-
initiated requests for funding to prepare and execute policies spe-
cifically addressing the central equity issue.
Governments and donors will have to enter into binding commitments
(with signed memoranda of understanding?) to move in the direction of
poverty alleviation and greater equity including the close monitoring
of progress. These binding commitments will be needed as a precondi-
tion for continued support. Funds would then be released in tranches
based on the achievement of negotiated verifiable indicators of pro-
gress along the line of project implementation. A donor-NGO/civil so-
ciety link and funding window should be developed concomitantly along
the same lines. In the case of non-responsive or non-performing gov-
ernments, donor funding earmarked for use by the latter should be
progressively reallocated to the NGO/civil society sector. Non-
performing NGOs should be dropped under the same guise. [See Schuf-
tan. C., "Foreign aid: Giving conditionalities a good name (A devel-
opment ethics with a South perspective)", D+C Development and Coop-
eration, No.4/1988].
All this may only add up to a start - and from the top at that. But it
is a start in the right direction. The road ahead will, for sure, re-
quire our greatest boldness ever.
For a change, let the more creative inputs on ways out of the dead-
end street of non-inequity-redressing individual targeting schemes
come from the more directly affected themselves. Devoting most of our
energies to facilitate just that process, will, by itself, be a big
leap forward.
Claudio Schuftan
Hanoi, Vietnam
mailto:aviva@netnam.org.vn
Acknowledgments: I would like to thank Goran Dahlgen for the improve-
ments he repeatedly suggested to me after patiently reading subse-
quent drafts.