# 1. Introduction - Describe the potential and limitations of different approaches to thinking about development, and their links to health in particular; - Explain how development is influenced by politics, and how these link to processes of power and governance in global health more broadly - Describe case studies of how the politics of development relate to selected global health issues; - Understand development as a key part of the governance challenge around global health To start to think about the politics in development let’s reflect on these two quotes – they offer very contrasting views on international development from the economist [[Jeffrey Sachs]] and from a representative of the UN Development program: > “Delusion and disappointment, failures and crimes, have been the steady companions of development and they tell a common story: it did not work” (Sachs, 2010) > “Most people today are healthier, live longer, are more educated and have more access to goods and services.” (UN Development Programme, 2010) This disagreement reflects how Development is inherently political – there are contests, conflicts and negotiations around what it should be and how it should be done, and who will benefit from it. The first quote is drawing attention to how some people have lost, the second to how some have gained. ## Key terms Economic development: Economic development is a process of increasing productive capacity and labour productivity (from Thomas, 2000). Human development: "Human Development is a development paradigm that is about much more than the rise or fall of national incomes. It is about creating an environment in which people can develop their full potential and lead productive, creative lives in accord with their needs and interests. People are the real wealth of nations. Development is thus about expanding the choices people have to lead lives that they value. And it is thus about much more than economic growth, which is only a means - if a very important one - of enlarging people's choices" (From www.undp.org). Community development: Development processes driven by, and oriented towards the needs of, communities. [[Gross Domestic Product (GDP)]]: the value produced by a country in a specific period, usually measured 'per capita', i.e. as an average figure for all people in a country. It is used as a measure of the standard of living. [[Human Development Index (HDI)]]: Human Development Index; an alternative measure to GDP of standard of living that measures incomes, education and health. [[structural adjustment]] Programme: Sets of policies adopted by countries following the debt crisis, in order to receive grants and loans from the [[World Bank (WB)]] and [[International Monetary Fund (IMF)]]. # 2. Development and health ## 2.1 Wealth and health is indirectly linked [[What are the policy implications of clear relationship between wealth and health?]] - [[Preston Curve]] However, we need to be cautious in making any simple link wealth and health since there are a range of mediating influences. As well as income, other additional factors like scientific breakthroughs and advancements in sanitation and hygiene are also important in linking wealth to health (Alsan et al. 2005). [[Preston concluded that the impact of income on health is only indirect]]. It can facilitate, but not necessarily lead to, greater consumption of food, housing and health services that can lead to better health (Preston, cited by Alsan et al. 2005). ^5a51d6 Another dimension of how a country’s wealth and health relate is inequality. As we saw, GDP per capita is an average figure, and tells us nothing about the distribution of income. [[Average GDP per capita is less reflective of typical income per person when income inequality is greater]] [[Health policymakers must see, that liberalisation that may resulted in aggregated increase in GDP, but it doesn't guarantee the distribution outcomes of trade]] ## 2.2 Wealth to health is the double burden of communicable and non-communicable disease [[Health and development has a bi-directional relationship that can be both vicious and virtuous in how they reinforce each other]] To further complicate our understanding of the wealth/health nexus, [[Potential for having good health with low economic growth|there is also the potential for having good health with low economic growth]] (Balabanova et al, 2011). Looking again at the Preston Curve, we can see there are countries that achieve good health at low levels of economic growth – these are the countries grouped around the top-left of the Preston chart (Figure 1); these include famous examples like Sri Lanka, Costa Rica and the Indian state of [[Kerala]]. It is worth focusing on the case study of Kerala – it has been much studied and talked about for its success in achieving social development. Kerala is “one of the poorest states in India”, yet despite continued poor economic growth it had a faster rate of income poverty reduction than the rest of India (Sen 1999) and higher levels of life expectancy than much richer populations (ibid). This has included dramatic reductions in infant mortality as well as progress on other health indicators (Gloyd 2004). [[Narrow focus on economic growth does not necessarily mean better health and social outcomes and could instead lead to rising inequality]] As we noted at the start of this section, much thinking on development tends to assume development means economic growth and increased wealth. Many believe it is reasonable to focus on economic growth alone, and to see it the same as development. This is because many aspects of development that countries may want to realize are only attained at higher income levels (Cypher and Dietz 2004). ==A narrow focus on economic growth has however been criticized, responding to some of the points we have just explored: that it doesn’t necessarily mean better health and social outcomes, and could instead lead to rising inequality – there are also other challenges we haven’t addressed such as the environmental damage that comes from certain approaches to seeking economic growth such as industralisation.== A dissatisfaction with a single focus on economic growth and GDP as a measure is mirrored in ideas of ‘human development’. This understanding of development has been heavily influenced by the work of writers like Amartya Sen and his work on development as freedom (Sen 1999). This line of thinking has led to the ‘[[Human Development Index]]’ or HDI, by the United Nations Development Programme. Rather than just using income or GDP as a measure of development, the HDI combines measures of health, education and income – seeing these as key aspects of ‘human development’. Economic growth is therefore included in the idea of human development, but is not the only focus. The Human Development Index creates a score which is used to measure a country’s development. #to-write One way to understand is through understanding 'growth-centered' or 'people-centered' approaches. A growth-centred development approach may for example focus resources and attention on supporting industry. This would be in the hope that it would lead to high economic growth, which in turn could be used to invest in health services and the broader social determinants of health. In contrast a ‘people-centred’ development approach that focused on human development might focus resources and attention on education and healthcare. This would be on the assumption that this would make people better able to contribute to the changes needed in society and so increase wealth, and also because they are good to do in their own right. These positions are just two of the many strands in development thinking, which are outlined in greater detail in the essential reading for the lectures by Thomas. ## 2.3 Key takeaways 1. [[Economic growth is necessary for development, but it is not sufficient]]. It is necessary because it leads to increases in incomes and living standards (Kambhampati 2004) but not sufficient, as we also need other changes to ensure progress on health and quality of life. 2. Further to this, there are a range of potential development paths – one way of understanding this is whether the path is closer to an economic growth or people centred development focus. Which path is taken reflects the outcome of political processes and who has the power to influence them. We will explore these political processes in the next section. # 3. Power and politics in development [[Three faces of power are layered. First face is domination, second face is agenda-setting, and third face is thought-control]] It is useful to think about development in terms of different ideologies and development pathways. China is seen as growth-centered development while Brazil is more people-centered development. [[Open Question]] What is Indonesia's ideology and how it affects development pathways? Are we drifting apart? Derailed from the initial purpose? #to-write Development policy therefore involves contests about different visions, and around which different political actors group. The reading by Tom Hewitt gives an insight in to the history of development, and if you read through that you can see how thinking around development has evolved giving some insight in to this idea of different development pathways. # 4. Issues in development ## 4.1 The State and the Market In an earlier lecture in the course, you studied the role of the state in health. This issue over the role of the state in funding and organizing health and other social services has been central to development policy. ==Debate and controversy have centred on whether the state supports or harms development== (Kambhampati, 2004). This debate usually links to an alternative position that can be defined as ’[[market–driven development]]’; i.e. rather than the state making decisions and planning and funding development processes, the market - i.e. the private sector, business and individual enterprise – should be left to pursue development themselves. The Thomas reading gives useful background on this debate and explores the different theories and ideologies on whether governments can and should support development. The differing ideas of growth-centred and people-centred strategies are useful here. From the 1980s onwards, the so-called ‘[[structural adjustment]] programmes’ have been a central focus for this debate. Structural adjustment was a set of policies promoted to resolve crises in development. These crises came about in the 1970s as many low-income countries took out loans and built up debt as they tried to fund their development programmes, and then ran in to trouble with shifts in the global economy, or by corruption and theft. Many countries across Africa and Latin America were left unable to pay back the loans they had taken out. The World Bank and IMF responded to this debt crisis by providing countries with money to borrow, on condition that these countries implemented ‘structural adjustment programmes’. These were seen as the way out of the debt crisis. Structural adjustment was meant to change the ‘structure’ of a country’s economy (see Cypher & Dietz, 2000) in order to stabilize the economy and restore economic growth (Mohindra 2007). The policies focused on liberalising – i.e. freeing up – the economy and privatising state owned industries, in order to increase the role of the market in development and – crucially- reduce the role of the state. The state was seen as a cause of economic problems and debt, and so its influence should be reduced. This package of policies became known as the ‘[[Washington Consensus]]’ - reflecting the close association with them of the World Bank, IMF and US treasury who are all based in Washington. ## 4.2 [[structural adjustment]] policies and the impact on health Impact is bad because it introduced user fees / out of pocket payment and led to a decline in people accessing health services (Rowden 2009). IMF also prohibited SIerra Leone and Liberia on health and social spending. ## 4.3 Global influence over national policy There are still concerns that policies emphasising growth over other goals dominate. The case of Tunisia is an example. Following the Arab spring and political revolution there, the World Bank and IMF have been engaged in providing loans and support to the new government. Some in Tunisia object to the policies being introduced for how they emphasise reducing state expenditure without sufficient attention to people’s needs. The issue of health financing and how this relates to development and the state role in this is still evolving. A focus for policy debate is now the concept of [[Universal Health Coverage]] – ensuring equitable access to essential health services without forcing people in to financial hardship. Previously, structural adjustment programmes subordinated health care spending to focusing on the goal of private sector led economic growth and development. With historical experience demonstrating the deficiencies in that approach and a growing recognition of the role of health in supporting development – as outlined at the start of this lecture – there is now more willingness to consider how governments can support health through direct spending. Indeed, that governments should support universal health coverage is now seen by many, including institutions like the World Bank, as central to achieving development. ## 4.4 Community development PHC refers to the provision of essential health care, universally accessible to individuals and families. It should form an integral part both of the country's health system and is the first level of contact of individuals, the family and community with the national health system - bringing health care as close as possible to where people live and work. Despite the high hopes, there has been concern at what has been achieved with PHC and other efforts towards community level development. Some see there has having been disappointing progress towards achieving the goals of PHC; a specific critique is that ==PHC was ‘depoliticised’== and the goals of community engagement and development sidelined, with PHC developing in to delivery of specific, basic health services. Some focused on the idea of ‘selective’ PHC, as achievable, considering resource constraints; this resource constraints reflecting the broader context of structural adjustment we have just spoken about (Global Health Watch, 2011). The central challenge is of community level participation and development happening within policy frameworks set elsewhere (Pieterse, 2000). Reflecting on the governance processes we have just described, we can see here how local processes of community development and engagement are wrapped up with, and are a part of, broader economic and political structures (Mohan and Stokke 2000). ==Whilst there may be a wish for communities to participate and control and pursue their own development, and achieve comprehensive PHC, other levels of power and decision making may inhibit this, and leave development processes far beyond the control of community level institutions.== [[Three faces of power are layered. First face is domination, second face is agenda-setting, and third face is thought-control|Think back to the first and second dimensions of power]]. Certain decisions a community will have less power over, and some decisions will not even be discussed with a community, with the agenda set elsewhere. So for example, a community may have some influence over where a clinic is located, but they then have no influence over, and may not even be able to discuss, the overall size of the health budget, or trade in pharmaceutical products, which all impact on the community level delivery of care and potential for development. A lesson here is of the need to be careful ==not to romanticize or demonize either community level processes or global power structures==, but to carefully consider who the ‘winners’ and ‘losers’ are and hold a critical perspective on all the actors and processes involved. ## 4.5 MDGs and SDGs [[Global norms can change, and engaging in global norm contestation is a political act that happens in a political stage, for example MDGs were able to achieve norm contestation that extreme poverty is morally unacceptable]] ## 4.5.1 Politics within the MDGs A reluctance to tackle these underlying issues can be seen as an effort to ensure that powerful countries, including the US and others, were kept involved in the process. It was felt by leaders within the UN that the MDGs could not challenge ideas of free markets, for example, as any effort to challenge these through the UN system would have led to considerable opposition (Hulme, 2010). ==Another example of such a political compromise within the MDGs and how they were tailored to specific political interests is around efforts to respond to the global challenge of poor sexual and reproductive health== (Davies, 2010). Reproductive health was initially not included in the goals following resistance from the US, the Vatican and a number of conservative Islamic states (Crane & Dusenberry, 2004; Hulme 2010). Later on, in 2007, reference to reproductive rights was added to the goals following long contest by many countries and NGOs (IPPF, 2012; Haslegrave, 2013). ## 4.5.2 The SDGs: Progress? The continuing powerful influence of developed country interests is also visible in how there were late adjustments to the supporting text of the goals to ensure that current norms around international trade were not threatened by the stated efforts to confront poverty and ensure equity amongst countries (Esquivel, 2016). Whilst the aims of the SDGs are ambitious and aim for transformation, as with the MDGs, there is therefore concern that tensions over governance are not being resolved, and barriers to achieving these goals are not being confronted. # 5. Healthy development? #to-write A useful idea to help us think about how to have ‘healthy development’ is that of ‘policy space’. Policy space refers to ‘the freedom, scope, and mechanisms that governments have to choose, design, and implement public policies to fulfil their aims’ (Koivusalo et al. 2009). Developing countries need this ‘policy space’ to allow development strategies to adapt to local issues. The policy space available to any country can be highly limited by the factors we have described above: outside agencies encouraging or determining certain policies, but also internal actors and groups that can limit policy space, for example through an authoritarian government that can limit the potential for effective policy. The current experience of Myanmar gives a powerful example of how the ‘policy space’ of a country can be limited and shaped by global and local processes. This will be explored further in the next activity. ## 5.1 Development activity #to-read Jasmine Burnley, Oxfam policy manager in Myanmar, recorded her perspectives for this lecture on some of the issues and tensions facing Myanmar. The recording was made in June 2016, following the movements towards democracy and opening up to global influences: https://ble.lshtm.ac.uk/mod/forum/view.php?id=274959 As you listen, reflect on the opportunities and potential limits on the policy space available for development in Myanmar and how this could impact on health. Jasmine's overview of key issues in Myanmar was very important for how it showed some of the pressures on the ‘policy space’ available for the new government – e.g. the pressures to ensure a role for the private sector in healthcare delivery - as well as how the Myanmar government and civil society attempted to make policy space to ensure some issues of local concern were addressed – such as land use rights. Since then, however, the situation Myanmar has changed dramatically. In February 2021, the Myanmar's military took power in a coup, halting abruptly the process of democratic transition and policy reform. Think about Jasmine’s insights and changes that have happened in the country recently, considering how they further constrain the policy space. Post your notes on the Moodle forum. # 6. Summary As we end the lecture, we’ll end with a summary of some key themes. In the lecture we initially explored how development and health are related, and identified how ‘wealthier can often mean healthier’, but that there are a range of factors shaping this relationship. We then analysed how development is shaped by politics and power, and this pointed us towards recognising the range of ways of thinking about it, and helped us move away from solely thinking of development as economic growth, and how there are potentially a range of goals and approaches to achieving them. We used the ideas of growth centred and people centred strategies as one way of thinking about this. Key issues of state reform, community development and the MDGs and SDGs have then highlighted different political dimensions of development, drawing attention to how development efforts are profoundly shaped by processes of power and governance, and in turn shaping the potential to achieve good health. Overall, in highlighting how development and health have important, as well as complex and numerous, links, we have highlighted how in any effort to take action on global health policy we must also consider how we can engage with and further processes of development. # 7. References ## 7.1 [[Essential readings]] Thomas A (2000). Meanings and Views of Development. Poverty and Development in to the 21st Century. Allen T & Thomas A (eds). Oxford University Press: Oxford. 23-48. [[@thomasVIEWSDEVELOPMENT]] This reading covers the ideas from the lecture about the complexity of development and how there is a range of ways of understanding and approaching it. The detail and arguments presented show us clearly how although certain ideas of development may dominate, there is nothing inevitable about this. The sections that discuss capitalism and its links to development have more detail than covered in the lecture, but this is useful background. There are many points included that provide detail to the distinction made in the lecture between economic and human development; the latter is linked to important strands in current development thought like participation and empowerment which you will come across in any wider reading in development. The discussion in the third part of the paper highlights the contested nature of development and how losers can arise from the process. Shrecker T (2009). Development and Health, in Introduction to International Development. Haslam PA, Schafer J & Beaudet P. Oxford University Press: Oxford. 345-66. This reading explores in more detail some of the ideas from the lecture, giving you chance to reflect in more depth on them; in particular, exploring the complexity of the links between health outcomes and development processes. The discussion on the overlaps between globalisation and development is also important, helping us understand how these processes are linked: that efforts to promote development have encouraged globalisation, with consequent impacts on the social determinants of health. The following discussion on the major institutions influencing development and health also adds to points made in the lecture about how their policies can have a damaging influence on health. ## 7.2 [[Recommended reading]] #to-read [[@harris10ThingsKnow2016]] Hewitt T (2000). Half a century of development. In: Allen T, Thomas A (eds) Poverty and Development in to the 21st Century. Oxford University Press: Oxford: 289-308. Not available Balabanova et al (2011) Good Health at Low Cost. Charlesworth Press; London. Available at http://ghlc.lshtm.ac.uk/ #to-read [[@ClimateEnergyEnvironment]]