Is accountability for health equity a blaming dance?

Alexandre Calandrini, from Unequal Voices, shares some reflections on the first day of the ‘Unpicking Power and Politics for Transformative Change: Towards Accountability for Health Equity workshop held at the Institute of Developing Studies (IDS)from 19-21 July.

Who is to blame?

In India, informal healthcare providers prescribe antibiotics to patients, sometimes even when it is not recommended. This can increase microbial resistance to these drugs, potentially leading to the spread of extremely serious infectious diseases.

Suppose you are an Indian health executive manager, who would you blame?

You could choose to blame informal healthcare providers. If so, you could decide to punish them by forbidding them to prescribe antibiotics. Weeks later, your local newspaper starts to question why infectious diseases are on the rise and more and more people dying from them. You might then realize that in India, as in many other places, a huge part of health care is delivered by informal providers. Forbidding them to prescribe antibiotics might address the antibiotic resistance, but it also then stops them from treating common infectious diseases, such as pneumonia or pharyngitis. In other words, you protect them against super infections, but make them an easy prey to treatable ones!

Now, let’s say you decide to blame the pharmaceutical industry instead, as they are the ones teaching (or pushing?) these informal providers to prescribe these drugs in what Abhay Shakka might describe as ‘fancy hotel’ seminars. Perhaps the way forward is to harshly punish “big pharma”. The next day, you are asked to leave the office, for whatever reason, except the actual reason which might be that a powerful politician made a call given that they happened to be financed by your most recently-acquired enemy.

Ok. Maybe blaming the microbes or the fatalistic understanding that people may die eventually from difficult-to-treat diseases is a more reasonable position which would allow you to hold onto your job.

Would you be satisfied with that? Probably not.

Let’s move then to how to regulate the private sector in the post-Soviet mixed health system of Mongolia. How would you do it?

That is the question Uranchimeg Tsevelvaanchig presented in the Pluralistic Health System session. She reinforced the need of a system perspective that defines the complimentary role of these early stage private providers, in a consistent policy, that not only focuses on isolated regulation, but combines it to a proper understanding of incentives. This immediately made me think on the Private sector regulation in Brazil, which has only started a few years ago, with an already huge health market in place. What if we (in Brazil) had strategically considered the private sector role right in the bginning of our Sistema Único de Saúde (and not simply stating its existence in our Constitution of 1988)? Perhaps we could have achieved a much more synergistic public-private mix than the one we have today. Well, I can´t go back in time. However, I can definitely learn from the Mongolian case, in search for insights.

What is accountability for health equity?

If you ask me what accountability for health equity is, I confess I would hesitate to give you a precise answer, simply because there isn’t a definitive one. This was another lesson from the session on historical concepts, definitions and language issues around accountability. As John Gaventa (IDS) put it (in a much better way than I’m able to recall), whichever way we frame the title (Social Participation? Social Accountability? Transparency?) – all still relevant for various reasons – the most important issue is to keep discussing what is under this umbrella term: social and health inequalities, democracy, and power: to, with and over.

As a medical student, my peers would probably show strong reservations about my presence in such an event. Not that I would blame them (I’m tired of reproducing the “blaming game”).It is hard. Sometimes the world’s problems are too big for you (shall I throw in the towel?). But then you notice that a solution for a problem you may be facing in your country seems to be popping up in China or India, and you think to yourself: “What if…?”.

As Vera Schattan Coelho told me during the workshop: “That’s IDS: a way to add complexity to our usual thinking”. Can’t wait for what comes out of this workshop.

Alexandre Calandrini is a medical student of Universidade Federal de São Paulo, Brazil 

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