At least half of the world’s population cannot obtain essential health services, according to a new report from the World Bank and the World Health Organization. And each year, large numbers of households are being pushed into poverty because they must pay for health care out of their own pockets.
Currently, 800 million people spend at least 10 percent of their household budgets on health expenses for themselves, a sick child or other family member. For almost 100 million people these expenses are high enough to push them into extreme poverty, forcing them to survive on just $1.90 or less a day. The findings, released today in Tracking Universal Health Coverage: 2017 Global Monitoring Report, have been simultaneously published in Lancet Global Health.
“It is completely unacceptable that half the world still lacks coverage for the most essential health services,” said Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization. “And it is unnecessary. A solution exists: universal health coverage (UHC) allows everyone to obtain the health services they need, when and where they need them, without facing financial hardship.”
“The report makes clear that if we are serious – not just about better health outcomes, but also about ending poverty – we must urgently scale up our efforts on universal health coverage,” said World Bank Group President Dr. Jim Yong Kim. “Investments in health, and more generally investments in people, are critical to build human capital and enable sustainable and inclusive economic growth. But the system is broken: we need a fundamental shift in the way we mobilize resources for health and human capital, especially at the country level. We are working on many fronts to help countries spend more and more effectively on people, and increase their progress towards universal health coverage.”
There is some good news: The report shows that the 21st century has seen an increase in the number of people able to obtain some key health services, such as immunization and family planning, as well as antiretroviral treatment for HIV and insecticide-treated bed nets to prevent malaria. In addition, fewer people are now being tipped into extreme poverty than at the turn of the century.
Progress, however, is very uneven.
There are wide gaps in the availability of services in Sub-Saharan Africa and Southern Asia. In other regions, basic health care services such as family planning and infant immunization are becoming more available, but lack of financial protection means increasing financial distress for families as they pay for these services out of their own pockets. This is even a challenge in more affluent regions such as Eastern Asia, Latin America and Europe, where a growing number of people are spending at least 10 percent of their household budgets on out-of-pocket health expenses. Inequalities in health services are seen not just between, but also within countries: national averages can mask low levels of health service coverage in disadvantaged population groups. For example, only 17 percent of mothers and children in the poorest fifth of households in low- and lower-middle income countries received at least six of seven basic maternal and child health interventions, compared to 74 percent for the wealthiest fifth of households.
The report is a key point of discussion at the global Universal Health Coverage Forum 2017, currently taking place in Tokyo, Japan. Convened by the Government of Japan, a leading supporter of UHC domestically and globally, the Forum is cosponsored by the Japan International Cooperation Agency (JICA), UHC2030, the leading global movement advocating for UHC, UNICEF, the World Bank, and WHO. Japanese Prime Minister Shinzo Abe, UN Secretary-General Antonio Guterres, World Bank President Kim, WHO Director-General Tedros and UNICEF Executive Director Anthony Lake will all be in attendance, in addition to heads of state and ministers from over 30 countries.
“Past experiences taught us that designing a robust health financing mechanism that protects each individual vulnerable person from financial hardship, as well as developing health care facilities and a workforce including doctors to provide necessary health services wherever people live, are critically important in achieving ‘health for all,’” said Mr. Katsunobu Kato, Minister of Health, Labour and Welfare, Japan. “I firmly believe that these early-stage investments for UHC by the whole government were an important enabling factor in Japan’s rapid economic development later on.”
The Forum is the culmination of events in over 100 countries, which began on Dec. 12—Universal Health Coverage Day—to highlight the growing global momentum on UHC. It seeks to showcase the strong high-level political commitment to UHC at global and country levels, highlight the experiences of countries that have been pathfinders on UHC progress, and add to the knowledge base on how to strengthen health systems and effectively promote UHC. In advance of the Forum, the UN General Assembly officially proclaimed 12 December as International Universal Health Coverage Day to raise awareness of the need for strong and resilient health systems that leave no one behind.
The main high-level sessions of the Forum take place tomorrow, Dec. 14, and will also feature an all-day “innovation showcase,” highlighting innovations driving progress in health systems around the world, and a celebratory public event in the evening. A commitment to action, called the Tokyo Declaration on Universal Health Coverage, will be released during the Forum’s closing ceremony.
“Without health care, how can children reach their full potential? And without a healthy, productive population, how can societies realize their aspirations?” said UNICEF Executive Director Anthony Lake. “Universal health coverage can help level the playing field for children today, in turn helping them break intergenerational cycles of poverty and poor health tomorrow.”
Building on the G7 Ise-Shima Summit and the TICAD VI in 2016, both of which stress the need for UHC, the Forum in Tokyo is seen as a milestone for accelerating progress towards the target of UHC by 2030, a key part of the Sustainable Development Goals. Countries will then gear up for the next global moment: a high-level meeting of the UN General Assembly on UHC in 2019.
Shame and stigma: The taboo of menstruating in South Asia
The beliefs and practices that revolve around menstruation differ across societies. In some cultures, the menstruating women are victimised due to the regressive attitudes that exist around menstruation. In others, menstruation as a topic is not up for discussion; it is covered in layers of shame and stigma. Nevertheless, what remains common for the women who go under this natural biological phenomenon is that there exist different battles. Actually, these battles have to be fought primarily as a result of some concepts that render women dirty and their bodies polluted; as not sacred enough to befit daily activities. These beliefs reduce women into untouchables and sometimes compel them to live in isolation.
In the region of South Asia, the practices vary from culture to culture, and there is a stark contrast between urban and rural societies. In Hindu societies, families host figurines of deities in their houses that are worshipped regularly with full devotion. The concept of sacred and profane is very widely present in such families, and menstruating women are considered profane. Living in the same space as the god is sacrilegious.
In Nepal, 19% women are banished from their houses to ‘chhaupadi goth’, roughly translating to menstruation huts. Chhaupadi is a practice in the mountainous western Nepal that forces women to sleep and live in sheds for the duration of their period, due to the belief that menstruating women cause ill-luck to the family, crops, and cattle if the god is displeased. The practice had been outlawed by the Supreme Court in 2005, and recently in 2017 was taken up in the parliament again because it caused death in huge numbers. In 2017 alone, the cases of Chhaupadi related deaths came up and it was immediately re-criminalised with a penalty for the offenders.
Despite this, the practice has not stopped. In interviews that were taken immediately as the nation was outraged by the frequent deaths that took place in western Nepal, the women were questioned if they would still practice Chhaupadior put their daughters through the same after the re-criminalisation and additional penalty. They responded that it was not up to them but on the very societies that coerced them to undergo such malpractice. Furthermore, criminalising the practice would mean filing formal complaints against the family members which is very unlikely. If the women had that kind of powers, they would not be banished to a shed in the first place.
Merely making and implementing of draconian laws is not enough because people house their belief systems in superstitious interpretation of religion. Vulnerable in those sheds, women fear snake bite and animal attacks, mosquitoes, asphyxiation due to inhalation of smoke from the fire built to fight the cold, and sexual predators among others. However, these families see it more deeming that a woman live in a shed outside the house in unsafe conditions just to prevent the house from being polluted by her presence. This all boils down to the fact that a death of a menstruating woman would be justified because at least, the god was spared from pollution, the crops and cattle were intact. It perhaps gets justified as a result of something she did, maybe touch a bottle of pickle, who knows?
A large section of the urbanised sectors lament, often in forms that take of troll posts and memes, about the so-called ‘feminists’ in the ‘East’ who limit their talk to menstruation to come off as empowered in contrast to the ‘feminists’ in the ‘West’ who battle real and important feminist issues like ‘equal pay’ and ‘glass ceiling’. Dissecting this, it dawns upon a realisation that people in these societies regard the women who talk about menstruation in the open as aggressively progressive. Moreover, they would rather dismiss the topic as something irrelevant and consider talking about it lesser important than talking about other inequalities. However, it is only fitting to be vocal about menstruation as much as required.
We forget to remember that women in remote areas with poor access do not benefit from the choice between various menstrual products at their disposal. In India, less than 16% of the women use marketed feminine products. In various parts of the country, women use sand, or wood shavings or pieces of cloth. Now, the issues that arise are of infections amongst other things. To begin with, these products are unsafe and pose a threat of infections like urogenital infection and bacterial vaginosis. The cloths are repeatedly used without being sun-dried because of the shame of exposure of the used cloths to men and other women. What also prevents these women from using hygienic safe products is due to unavailability for several kilometres, unaffordability arising out of poverty, and embarrassment to ask for even a sanitary pad, especially from male shopkeepers. In fact, 23% of the girls drop out of school upon starting their menstruation. The Indian government, along with entrepreneurs, and educators have worked hard to ensure all women have access to sanitary products. However, the lack of funds, expensive to afford one-use products, unable to maintain quality of the low-budgeted products, and failure to meet the needs of all women in the country are some problems that are faced.
In Pakistan, 80% women do not have access to sanitary menstrual products. UNICEF reported that the biggest hindrance to sanitary conditions was prevented by the lack of washing facilities. In fact, for a country frequented by natural calamities and insurgencies in some areas, women should be educated and encouraged about using hygienic productssince there is always the likelihood of moving to temporary shelters in such circumstances. It was reported that a stunning number of girls are shocked upon menstruating their first time because they were not aware about it. In only a few years to follow, many drop out of school or stay absent from school when they are menstruating, thus hindering their education.
To sum it up, menstruation has been evolved as a shameful event in this part of the world. Menstruating women are shunned and indoctrinated as inferior and unchaste and they do not even fight against the practices but accept it as normal. Firstly, religion has a significant part to play as it is due to the god-fearing purity seeking individuals that seek to maintain the sanctity of their surroundings from where the concept of sacred and impure arise. But, how can any practice be religious if it causes the already disadvantaged more detriment? Secondly, unawareness and equating menstruation with shame and secrecy has worsened the situations to where women are not comfortable with their own bodies so much so that they from birth to death are unaware of their own anatomies. Where mothers are themselves not at peace with their body and bodily functions, passing it on to their daughters is difficult and discussing about it with their sons unimaginable. Lastly, this exclusion of men and terming menstruation as a ‘woman thing’ has led to men genuinely having no idea what the deal is about and why is it important for women to be safe, clean, healthy, and rested when they menstruate. Thus, a change is necessary by educating women, by subsiding sanitary menstrual products, criminalising discrimination against menstruating women, and by including men in this drive.
Invisible and Excluded: The Fate of Widows and Divorcees in Africa
Across Africa, the impact of marital death and divorce falls more heavily on women, who may be excluded socially and lose their home and property after a marriage ends. One in ten African women above the age of 14 is widowed, and six percent are divorced. Many more have been widowed or divorced at some point in their lives.
“In the face of divorce or widowhood, women often struggle with serious economic hardship,” said Asli Demirguc-Kunt, Director of Research at the World Bank. “Unfortunately, designing effective policies to prevent these women from falling into poverty is hamstrung by sparse data and research.”
At a recent Policy Research Talk on the issue, Dominique van de Walle, a Lead Economist at the World Bank, argued that providing widows and divorcees a secure foothold in society is central to the broader struggle for gender equality. In much of Africa, marriage is the sole basis for women’s access to social and economic rights, and these are lost upon divorce or widowhood.
Women frequently inherit nothing when a marriage ends, and official legal systems offer little recourse. Some may even lose their children to the husband’s lineage. Broader patterns of gender inequality add to the heavy burden on women’s shoulders. They are shut out of labor markets, have fewer productive assets, and bear greater responsibility for the care of children and the elderly.
Just as widows are often hidden from view in their own communities, the absence of data limits broader public awareness of the issue. Quantifying the prevalence of widowhood and divorce requires information on both current widows and divorcees as well as the marital history of currently married women, and this is only available in 20 countries.*
The numbers show that brief marriages are a fact of life for many. Women tend to get married while young to much older men, and men are more likely to die in work-related accidents or in conflict. Many also succumb to HIV/AIDS. In addition, men who lose a spouse are much more likely to remarry than women, in part because of polygamy which is legal in 25 countries.
The options open to widows and divorcees after a marital dissolution vary greatly based on age, ethnicity, and social norms, but are often limited. In some regions, young widows are encouraged to remarry. Levirate marriage—a tradition in which a widow marries a relative of the deceased husband—provides a modest safety net, but the remarried widow often occupies an inferior position in the new household. In Senegal, for example, levirate marriage is associated with the lowest consumption levels for previously widowed women. These marriages can act as a poverty trap for those who cannot refuse due to a lack of means. In other settings, widows and divorcees may be shunned, ostracized, and dispossessed.
Divorcees and widows are also much more likely to suffer other forms of disadvantage. Relative to similar women in their first union, both groups have worse nutritional outcomes on average across Africa. In Malawi widows are five times more likely than women who are married (and never widowed) to be HIV positive. Divorcees are not far behind.
“The prevalence of HIV varies enormously across marital status, with widows having the highest rates of HIV infection in most countries where we have data,” said van de Walle. “These women are doubly disadvantaged, and societies often do little to help them cope with this extraordinary challenge.”
The disadvantages that widows and divorcees suffer also affect their families. Research in Mali shows that the children of widowed mothers have worse health and are less likely to be enrolled in school. In Zambia, in areas where customary rights do not support land inheritance for widows, married couples make fewer productive investments in their land. Where widows and divorcees suffer, society at large suffers as well.
Policy Can Help Address the Disadvantages Faced by Widows and Divorcees
“In many settings, working with the affected women solves one part of the problem,” said Bénédicte de la Brière, a Lead Economist at the World Bank. “But there also needs to be broader engagement with the community at large, and especially those in power.”
The right policy measures could shield widows and divorcees from the threat of poverty. Given the variety of countries, institutions, and legal systems covered in van de Walle’s research, no single policy formula applies across the board. Rather, policy makers will have to stitch together policies to fit their specific circumstances.
Policies that address systemic inequalities can enable women to support themselves in the face of a marital dissolution. These include reforms to credit markets, where women are particularly disadvantaged; ensuring equal ownership and inheritance rights for women; and securing customary marriages through registration and legal documentation.
Responsive policies can buoy widows and divorcees after a marriage ends. A widow’s pension can serve as a temporary safety net, as long as the benefits are transferred directly and securely to widows. Preferential access to housing and shelters is another measure that could help widows and divorcees in the event of a marital dissolution.
But van de Walle cautioned that research on the effectiveness of these policies is limited. The fate of widows and divorcees may depend on the willingness of African countries to invest in their most vulnerable people by evaluating whether these policy options notably improve the financial stability and social standing of their widows, divorcees, and their families.
* Data for these 20 countries were obtained through Demographic and Health Surveys fielded between 2004 and 2013. The data are further limited by the fact that they only cover women aged 15-49 and, for currently married women, only cover how a previous union ended but not a full marital history.
Source: World Bank
An education approach to preventing and countering violent extremism
Last November Goodenough College and The Royal Commonwealth Society brought together four experts to discuss and debate the role that education can play in putting youth at the forefront of fostering stability, change, and a peaceful future.
The justification for putting youth at the heart of these issues is simple – youth are often seen as the most vulnerable to turn to violent acts, but what is habitually left out is their capacity to be agents for change, and their ability of bringing new and innovative ways to address the issues of today. Secondly, the youth population is only growing, currently now 60 percent of Commonwealth citizens are under the age of 30.
There is a global shift towards the recognition that robust and quality education can play a critical role in preventing and countering violent extremism. A lack of quality education, just as poverty, bad governance and the absence of rule of law, creates a ‘push factor’ and raises the tensions that can make people more susceptible to a violent extremist narrative. Robust education can, among other things, encourage critical thinking, cultural awareness, respect and understanding, tolerance and cultures of peace. These attributes help create an environment whereby young people are more likely to resist the ‘pull factors’ that can lead them to employ or support the use of violence to express their grievances.
However, education on its own is not sufficient to prevent violence. Not all education inspires peaceful environments, and not all education can be classified as CVE work. The right to education is critical, but simply promoting education is not enough to prevent terrorism. We know this as many violent extremists are well educated. Secondly, education systems can in themselves be based along class or ethnic lines creating more grievances, and curricula can be written in a way that encourages discrimination and hate.
Tackling violent extremism through education must have a three-pronged approach. We can use formal and informal education to directly discuss the issues driving violent extremism and catalyse community action and local solutions. We can develop effective curriculums and equip teachers with tools to encourage critical thinking and respect and tolerance. Finally, we can work with governments to overhaul education systems to ensure that they are inclusive environments that encourage peace and dialogue.
These are some of the approaches that education ministers will consider at their summit in Fiji next month. The Commonwealth’s joined-up approach to development work means that governments can benefit from initiatives in our CVE unit as well as key resources from our education team, such as the Education Policy Framework and the Curriculum Framework for the Sustainable Development Goals which offer step-by-step guides that ministries can use to improve and modernise education policies and curriculums.
A version of this blog was originally published in the Royal Commonwealth Society’s Commonwealth Voices December 2017
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