Academic journal article Journal of Health Population and Nutrition

Can Social Inclusion Policies Reduce Health Inequalities in Sub-Saharan Africa?-A Rapid Policy Appraisal

Academic journal article Journal of Health Population and Nutrition

Can Social Inclusion Policies Reduce Health Inequalities in Sub-Saharan Africa?-A Rapid Policy Appraisal

Article excerpt


"A child born in Africa faces more health risks than a child born in other parts of the world. Such a child has more than a 50% chance of being malnourished, a high risk of being HIV-positive at birth while malaria, diarrhoeal diseases, and acute respiratory infections account for 51% of deaths. A child born in the African region is more likely to lose his/her mother due to complications in childbirth or HIV/AIDS while that child has a life-expectancy of just 47 years and is very likely-at least once in his/her short life-to be affected by drought, famine, flood or civil war, or become a refugee" (1).

Sub-Saharan Africa remains the world's poorest region with almost half of its people living on less than one dollar a day (2,3). Sub-Saharan Africa also bears the brunt of global health inequalities, with high levels of undernutrition, 50% of maternal and child deaths, and a high burden of infectious diseases, including HIV and AIDS, malaria, and tuberculosis (1,3).

The growing global interest in the social determinants of health provides an opportunity for determined action on unacceptable and unjust health inequalities that exist within and between countries (4). This paper presents a rapid appraisal of policies, programmes, or actions that have the potential to address social exclusion and reduce health inequalities in six selected countries: Botswana, Mozambique, South Africa, Ethiopia, Nigeria, and Zimbabwe. The term 'health inequalities' refers to the systematic and unfair differences in health experience or outcomes between different socioeconomic groups within or between societies or countries. The paper draws on the research conducted by the Social Exclusion Knowledge Network (SEKN), one of nine global knowledge networks, set up to support the work of the World Health Organization's (WHO's) Commission on Social Determinants of Health (CSDH).

In the first part of the paper, we use the model of social exclusion developed by the SEKN to outline the approach to, and the limitations of, the appraisal of policies. In the second section of the paper, we briefly describe the policies selected for appraisal and whether or what the impact of these policies has been on health inequalities. The factors that enable and hinder the implementation of the policies were also analyzed. The conclusion contains key messages to governments and civil society in sub-Saharan Africa on steps that can be taken to support the global goal of improving health and reducing health inequalities.

Approach to appraisal of policies

The social exclusion concept has become central to the policy and academic discourse in the European Union and Canada in the last two decades (5,6). However, social exclusion is a problematic concept in sub-Saharan Africa as the majority of people live in poverty. Alternative discourses of poverty, marginalization, vulnerability, and sustainable development continue to have more policy leverage and have received much critical attention. Nevertheless, the notion of social exclusion appears increasingly in African declarations on the 'developmental state' and in-country anti-poverty programmes (7-9).

Given the contested nature of the concept, the SEKN proposed a relational understanding of social exclusion that focuses on processes driving inequalities in health and other domains of life, rather than a static approach focusing on arbitrary lists of variables or particular groups of 'excluded' people (6). The SEKN's definition of social exclusion is given below:

"Exclusion consists of dynamic, multi-dimensional processes driven by unequal power relationships. These operate along and interact across four dimensions- cultural, economic, political and social- and at different levels, including individuals, groups, households, communities, countries and global regions. Exclusionary processes contribute to health inequalities by creating a continuum of inclusion/exclusion. This continuum is characterized by an unjust distribution of resources and unequal capabilities and rights required to:

* Create the conditions necessary for entire populations to meet and exceed basic needs

* Enable participatory and cohesive social systems

* Value diversity

* Guarantee peace and human rights

* Sustain environmental systems" (6). …

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