Papers

• Is It Time for a New Vision for Health Equity? Catherine Smith Macquarie University

  Although medical anthropologists have long emphasised the social, economic, political and historical basis for global health disparities, expanding access to quality medical care has long been seen as the principle solution to address health inequalities. Taking up the case studies of malaria elimination and global maternal health, this paper suggests that we are at a timely point to reinvigorate critical medical anthropology and bring about new approaches to health equity that go beyond expanding biomedical care. For both malaria elimination and maternal health, internal health disparities are not only becoming more apparent, they are becoming increasingly fluid, and shaped by shifting social and political processes in addition to more enduring social determinants of health. In many malaria elimination settings, social and political processes have come to shape disease vulnerability to a greater extent than physiological risk. In the case of maternal health, we are at a stage where many women globally continue to struggle to access care while many others suffer from the overmedicalization of childbirth including coercive health interventions. All of this is even more sobering when we look to wealthier countries such as Australia, and see that internal health inequalities that are grounded in social injustice do not disappear even after the development of excellent healthcare systems. This paper is intended as an exploratory paper to ask what conditions might be necessary to enable health initiatives to better respond to complex socio-political transformations in ways that better support social resilience and social justice. It argues that contemporary transformations in the global health landscape call for new approaches to health equity, and that a starting point should be to reconceptualize global health problems as multidimensional social problems that carry tragic embodied effects.

• Obscuring Inequities: A Case of Global-Local Partnerships in HIV Research and Intervention in Indonesia Sutarsa Nyoman Australian National University

  Throughout this paper, I discuss how local actors have facilitated global – local partnerships both in scientific and program implementation projects. Partnerships, or the act of domination from western institutions can be viewed as pull and push manoeuvre involving power contestations and economic struggle between local elites and global collaborators. Drawing from my co-authorship analysis and extended field work in Bali Province, HIV research agenda and HIV programming at the locality are heavily influenced by the interests of global collaborators under the rhetoric of fair and mutual collaborations. Thus, global – local alliances in Indonesia has reinforced a power dynamic and skewed further the already asymmetrical power configurations between local partners and international counterparts. As a result, the imagination of equal and mutual partnership becomes untenable. Knowledge produced from scientific collaboration and vertical program implementation is no longer solely a public good, but rather is treated as a new ‘material’ to attract more financial and social resources. Knowledge associated with HIV epidemic for example, mirroring the wave-like epidemic model promoted by western institutions, has coloured the HIV epidemiology and behavioural studies for the last three decades. The mimicry of HIV research agenda in Bali Province from early 1990s until now is facilitated by the dependency of local researchers and institutions on foreign research grants and programs, which effectively creates fertile environments for academic neo-colonialism. Emerging HIV research at locality is designed to provide answers that matter to western societies, or at worse to confirm western scientific discovery using samples and patients from locality. What emerges from these global – local partnerships is the global division of labour in knowledge production where local partners always at the receiving end of such processes.

• Paradox and Ambivalence of Biomedicalization: Rising Caesarean Section Rates and Persistent Preference for Vaginal Delivery in Contemporary Vietnam Myriam de Loenzien French Research Institute for Development

  Over recent decades, maternal and neonatal health conditions have greatly improved in Vietnam in a context of medicalization. The proportion of women undergoing caesarean section (CS) is among the highest in the region. This raises concerns due to the sanitary, human, social and economic costs attached to its overuse. To better understand this process, we examine the way delivery and CS practice have developed during the last decades, and explore women’s subjectivities associated with these phenomena. We use data from nationally representative surveys from 1997 to 2014, and results from qualitative interviews realized with 15 nulliparous women in Hanoi in 2017.

  Results show that in a context of reducing disparities and rising caesarean section rates reaching high levels especially in urban areas, preference for vaginal delivery remains strong. Women attribute recourse to CS to difficulty to deliver but also to social constraints and willingness to deliver at a propitious time. In a context of lack of preparation for childbirth, CS helps them to deal with uncertainty, fear of childbirth and poor healthcare quality notwithstanding the availability of high level technology equipment. Despite many drawbacks, CS is viewed as a way to avoid potential problems in sexual life due to consequences of vaginal delivery on the women’s body. In a context where lifestyles are rapidly changing, CS is interpreted as a sign of women’s modern “weakness”. The ambivalence surrounding CS results from organizational healthcare constraints but also multiple and contradictory injunctions faced by women when dealing with their family, the medical personal and their social environment. In a context of long lasting promotion of equality by the government but also increasing role of the Internet, recourse to caesarean section is associated with inequalities whose meaning is ambivalent and significant of evolving social and biomedical norms.

• The State of Health, Delivery of Health Services and Equity of Access in Metro Manila: Successes, Challenges and Possible Ways Forward Maria Ela Atienza University of the Philippines

  The health sector is the largest service that has been devolved to local governments as a result of the 1991 Local Government Code in the Philippines. However, available literature suggests that devolution has not resulted automatically to improved health service delivery and greater access to health services across local government units (LGUs). Decentralization has not always resulted in greater efficiency, equity and effectiveness in the health sector. There is uneven progress in this area across Philippine LGUs. Statistics suggest that human resources, budget, and facilities for health are spread unevenly across the country, with Metro Manila (the National Capital Region composed of 16 cities and one municipality) and other urban centers enjoying more of these. However, another important question is whether health services are accessible for all. It appears from various literature that the poor are not getting access according to their needs.

  What this study intends to do is to look into the status of health and utilization of health services in Metro Manila, the most populous and most densely populated region in the Philippines as well as the economic center which accounts for 37% of the country’s GDP. This paper looks into regional and LGU levels with national comparisons. First, the paper will briefly look into the existing devolved structure of health services in the country as well as in Metro Manila. Second, the paper will assess the health status in Metro Manila in general and within the LGUs, looking into various health indicators. Third, the paper will assess the utilization of health services in Metro Manila and its LGUs and check on access and equity issues. Finally, the paper concludes with the overall assessment of the health status, service delivery and utilization of health services in Metro Manila and its LGUs, emphasizing positive areas as well as problem areas. The final section will also propose some policy recommendations for the improvement of health services and access to these. These policy recommendations can be within the current devolved framework or other alternative arrangements and policies, e.g. federal arrangements as advocated by the current national administration or an autonomous metropolitan region, applicable in particular to the Metro Manila area.

  This paper uses the human security approach and will rely mostly on available qualitative and quantitative data and assessments of health status and services in Metro Manila and the Philippines, including LGU budgets, Department of Health data, poverty data, and the National Health and Demographic Surveys. Independent assessments conducted by private foundations and groups will also be included in the assessment.

Abstract

Keywords

• Asia Pacific
• Body
• Health