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SECTION 1 2 3 WHAT CAN BE DONE CASE STUDY GHANA: WEAK HEALTH SYSTEMS COST THE POOREST THEIR LIVES Babena Bawa was a farmer from Wa East district; a remote and underdeveloped area in the upper-west region of Ghana, where seven health centres serve a population of nearly 80,000 people. There are no hospitals, no qualified medical doctors and only one nurse for every 10,000 people. In May 2014, Babena died of a snake bite that would have been easily treatable, had any of the health centres in his district stocked the necessary anti-venom. Instead his last hours on earth were spent in a desperate race against time to reach the regional hospital, 120km away. The road to the regional centre was too poor and the journey too long, and he died before making it to the hospital. The story of Babena stands in stark contrast to that of presidential candidate Nana Akufo-Addo. When faced with heart problems in 2013, he was able to fly to London for special treatment. Public services have the power to transform societies by enabling people to claim their rights and to hold their governments to account. They give people a voice to challenge unfair rules that perpetuate economic inequality, and to improve their life chances. It is estimated that if all women had a primary education, child marriage and child mortality could fall by a sixth, while maternal deaths could be reduced by two‐thirds. 414 Moreover, evidence shows that public services can be great equalizers in economic terms, and can mitigate the worst impact of today’s skewed income and wealth distribution. OECD countries that increased public spending on services through the 2000s successfully reduced income inequality and did so with an increasing rate of success. 415 Between 2000 and 2007, the ‘virtual income’ provided by public services reduced income inequality by an average of 20 percent across the OECD. 416 Long-term trends in poorer countries echo these findings. Studies show that taking the ‘virtual income’ from healthcare and education into account also decreases real income inequality by between 10 and 20 percent in five Latin American countries: Argentina, Bolivia, Brazil, Mexico and Uruguay. 417 In 11 out of 12 Asian countries studied, government health spending was found to be ‘inequality reducing.’ 418 Education played a key role in reducing inequality in Brazil, 419 and has helped maintain low levels of income inequality in South Korea. 420 However, the extent to which public services are able to achieve their inequality-busting potential depends on how they are designed, financed and delivered. Unfortunately today, in too many cases, the policy choices being made punish the poor, privilege elites, and further entrench pre‐existing economic inequality. 90
SECTION 1 2 3 WHAT CAN BE DONE THE LOW ROAD: CUTS, FEES, PRIVATIZATION AND MEDICINES FOR THE FEW Universal public services are a strong tool in the fight against inequality. But the domination of special interests and bad policy choices – budget cuts, user fees and privatization – can make inequality much worse. Low levels of public spending and cuts Governments in many countries are falling far short of their responsibilities. The Indian government spends almost twice as much on its military as on health. 422 In Africa, only six countries have so far met the Abuja commitment to allocate 15 percent of government spending to health. Between 2008 and 2012 more than half of developing countries reduced spending on education, while two-thirds decreased spending on health. 423 “ Even tiny out-of-pocket charges can drastically reduce [poor people’s] use of needed services. This is both unjust and unnecessary. JIM YONG KIM PRESIDENT OF THE WORLD BANK GROUP 421 “ There is also an imbalance, which skews public spending on health and education in favour of the already better-off urban areas, and away from investing in schools and health centres in poorer rural areas. Better quality services tend to be concentrated in big cities and towns. In Malawi, where the level of public spending per primary school child is among the world’s lowest, a shocking 73 percent of public funds allocated to the education sector benefit the most educated 10 percent of the population. 424 When public services are not free at the point of use, millions of ordinary people are excluded from accessing healthcare and education. Every year, 100 million people worldwide are pushed into poverty because they have to pay out-of-pocket for healthcare. 425 A health emergency can doom a family to poverty or bankruptcy for generations. Paying for healthcare exacerbates economic inequality in rich countries too: in the USA, medical debt contributed to 62 percent of personal bankruptcies in 2007. 426 Fees still cost some people the earth School fees have been shown to be a common deterrent to enrolment, especially at secondary school level, where they persist more widely. This is because the poorest simply cannot afford to send their children to schools that charge fees, even when such fees are considered ‘low’. Women and girls suffer most when fees are charged for public services. In many societies, their low status and lack of control over household finances mean they are last in line to benefit from an education or receive medical care. Even the World Bank Group – a long time promoter of user fees – has altered its profee stance. Yet they continue to exist in many of the world’s poorest countries. “ I went for a cataract operation. They told me it costs 7,000 Egyptian pounds. All I had was seven so I decided to go blind. A 60-YEAR OLD WOMAN IN A REMOTE VILLAGE IN EGYPT “ 91
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