Can Short-term Economic Policies Hurt the Health of the Poor? Demonetization in India.

In November 2016, the Government of India (GOI) demonetized the commonly used Rs500 and Rs1,000 denominations. This was a short-term economic policy, known as notebandi, implemented as a means to address black money, counterfeit currencies, and terrorist activities. Notebandi was unrolled in a chaotic, confusing, and complex manner, leaving many people with limited access to cash in their daily activities. And the poor, who tend to earn their livelihoods from cash, were faced with economic exclusion and even destitution. In this paper, we argue that demonetization had disproportionately negative consequences on the poor and trace the main pathways between demonetization and the health of the poor. We conclude by calling on public health researchers to monitor and evaluate the health consequences of India's latest demonetization and to rapidly assess future policy initiatives in order to help advise governments in devising and implementing economic policies that does not harm the health of people, especially the poor.

Research and the health of indigenous populations in low- and middle-income countries.

In low- and middle-income countries (LMICs)-when there are available data-a 'health divide' exists between indigenous and non-indigenous populations living in the same society. Despite the limited available evidence suggesting that indigenous populations have high levels of health needs, there is scant research on indigenous health, especially in Africa, China and South Asia. Pursuing research, however, is clouded by the prior negative experiences that indigenous populations have had with researchers. In this paper, we describe the current evidence base on indigenous health in LMICs, propose practical strategies for undertaking future research, and conclude by describing how global health researchers can contribute to improving the health of indigenous populations.

Globalization and the rise of precarious employment: the new frontier for workplace health promotion.

Global market integration over the past three decades has led to labour market restructuring in most countries around the world. Employment flexibility has been emphasized as a way for employers to restructure their organizations to remain globally competitive. This flexibility has resulted in the growth of precarious employment, which has been exacerbated by the global financial crisis and resulting recession in 2007/2008, and the ongoing economic uncertainty throughout much of the world. Precarious employment may result in short and long-term health consequences for many workers. This presents a deeper and more structural determinant of health than what health promoters have traditionally considered. It calls for a different understanding of workplace health promotion research and intervention that goes beyond enabling healthier lifestyle choices or advocating safer workplace conditions to ensuring adequate social protection floors that provide people with sufficient resources to lead healthy lives, and for advocacy for taxation justice to finance such protection.

Towards the next generation of public health research in India: a call for a health equity lens.

BACKGROUND: Public health research is at a cross road in India. Despite a high level of health needs and new public health challenges arising in the context of rapid economic growth and social change, public health research is not keeping up with the needs of Indian society. There are, however, new initiatives creating opportunities to increase public health research, thereby raising debates about public health research priorities. OBJECTIVE: In this paper, the authors offer their own view on an agenda for the next generation of public health research in India. FINDINGS: The authors first outline the main reasons why they believe that public health research has been sidelined in India. Then, the authors argue that health equity should be the overarching principle guiding a public health research agenda. The authors suggest how to integrate equity-oriented strategies into the public health research agenda and propose some key research questions that require urgent attention from their respective disciplines.

Alcohol use and its consequences in South India: views from a marginalised tribal population.

BACKGROUND: Alcohol consumption in India is disproportionately higher among poorer and socially marginalised groups, notably Scheduled Tribes (STs). We lack an understanding of STs own views with regard to alcohol, which is important for implementing appropriate interventions. METHODS: This study was undertaken with the Paniyas (a previously enslaved ST) in a rural community in Kerala, South India. The study, nested in a participatory poverty and health assessment (PPHA). PPHA aims to enable marginalized groups to define, describe, analyze, and express their own perceptions through a combination of qualitative methods and participatory approaches (e.g. participatory mapping and ranking exercises). We worked with 5 Paniya colonies between January and June 2008. RESULTS: Alcohol is viewed as a problem among the Paniyas who reported that consumption is increasing, notably among younger men. Alcohol is easily available in licensed shops and is produced illicitly in some colonies. There is evidence that local employers are using alcohol to attract Paniyas for work. Male alcohol consumption is associated with a range of social and economic consequences that are rooted in historical oppression and social discrimination. CONCLUSION: Future research should examine the views of alcohol use among a variety of marginalised groups in developing countries and the different policy options available for these populations. In addition, there is a need for studies that untangle the potential linkages between both historical and current exploitation of marginalized populations and alcohol use.

Women's health in developing countries: beyond an investment?

Most international programs and policies devised to improve women's health in developing countries have been shaped by powerful agencies and development ideologies, including the tendency to view women solely through the lens of instrumentalism (i.e., as a means to an end). In a literature review, the authors followed the trail of instrumentalism by reviewing the different approaches and paradigms that have guided international development initiatives over the past 50 years. The analysis focuses on three key approaches to international development: the economic development, public health, and women-gender approaches. The findings indicate that progressive changes have adopted a more inclusive development perspective that is potentially beneficial to women's health. On the other hand, most paradigms have largely viewed improving women's lives in general, and their health in particular, as an investment or a means to development rather than an end in itself. Public health strategies did not escape the instrumentalism entrenched in the broader development paradigms. Although there was an opportunity for progress in the 1990s with the emergence of the human development and human rights paradigms and critical advances in Cairo and Beijing promoting women's agency, the current Millennium Development Goals project seems to have relapsed into instrumentalism.

A systematic review of population health interventions and Scheduled Tribes in India.

BACKGROUND: Despite India's recent economic growth, health and human development indicators of Scheduled Tribes (ST) or Adivasi (India's indigenous populations) lag behind national averages. The aim of this review was to identify the public health interventions or components of these interventions that are effective in reducing morbidity or mortality rates and reducing risks of ill health among ST populations in India, in order to inform policy and to identify important research gaps. METHODS: We systematically searched and assessed peer-reviewed literature on evaluations or intervention studies of a population health intervention undertaken with an ST population or in a tribal area, with a population health outcome(s), and involving primary data collection. RESULTS: The evidence compiled in this review revealed three issues that promote effective public health interventions with STs: (1) to develop and implement interventions that are low-cost, give rapid results and can be easily administered, (2): a multi-pronged approach, and (3): involve ST populations in the intervention. CONCLUSION: While there is a growing body of knowledge on the health needs of STs, there is a paucity of data on how we can address these needs. We provide suggestions on how to undertake future population health intervention research with ST populations and offer priority research avenues that will help to address our knowledge gap in this area.

Making sense of the global economy: 10 resources for health promoters.

Population health is shaped by more than local or national influences-the global matters. Health promotion practitioners and researchers increasingly are challenged to engage with upstream factors related to the global economy, such as global prescriptions for national macroeconomic policies, debt relief and international trade. This paper identifies 10 books (A Brief History of Neoliberalism, Bad Samaritans: The Myth of Free Trade and the Secret History of Capitalism, The World is Not Flat: Inequality and Injustice in Our Global Economy, Globalization and its Discontents, The Debt Threat: How Debt is Destroying the Developing World, Global Woman: Nannies, Maids, and Sex Workers in the New Economy, A Race Against Time, Globalization and Health: An Introduction, Global Public Goods for Health: Health Economics and Public Health Perspectives, Trade and Health: Seeking Common Ground) and several key reports that we found to be particularly useful for understanding the global economy's effects on people's health. We draw attention to issues helpful in understanding the present global financial crisis.

"My story is like a goat tied to a hook." Views from a marginalized tribal group in Kerala (India) on the consequences of falling ill: a participatory poverty and health assessment.

BACKGROUND: Indigenous populations tend to have the poorest health outcomes worldwide and they have limited opportunities to present their own perspectives of their situation and shape priorities in research and policy. This study aims to explain low healthcare utilisation rates and opportunities to cope with illness among a deprived indigenous group - based on their own experiences and views. METHODS: A participatory poverty and health assessment (PPHA) was conducted among the Paniyas, a previously enslaved tribal population of South India in a Gram Panchayat in Kerala, India in 2008. Purposive sampling was used to select five Paniya colonies, involving 66 households. RESULTS: There were four key findings. First, Paniyas' perception that the quality of the public healthcare system is poor leads them to seek suboptimal care or deters them from using services. Second, there are significant costs of care unrelated to service use or purchase of medicines, such as travel costs, which the Paniyas lack the ability to pay. Third, illness can lead to loss of productive opportunities among those who fall ill and those who provide informal care. Fourth, the Paniyas lack a 'range' of coping strategies as they are wage labourers without diverse sources of income. They rely on a single strategy: borrowing from outside their community, often from landowners and employers, to whom they become indebted with their labour. CONCLUSIONS: Improving the capacity of tribal populations to present their own perspectives is likely to lead to more effective tribal development policies and consequently better health.

Evaluating the unintended health consequences of poverty alleviation strategies: or what is the relevance of Mohammed Yunus to public health?

Public health researchers are increasingly shifting their attention away from merely documenting those factors that determine health--a solid evidence base on health determinants now exists--to improving our understanding of how various interventions influence population health. This paper argues for greater investigations of the potential unintended health benefits associated with participation in a poverty alleviation strategy (PAS) in low-income countries. We focus on microcredit, a PAS that has been spreading across the developing world. Microcredit aims to address the "credit gap" between the poor and the better off by offering an alternative for the poor to acquire loans: small groups are formed and loans are allocated to members based on group solidarity instead of formal collateral. We argue that microcredit corresponds with activities that will help build up health capital (e.g., greater access to resources) and describe the main pathways from microcredit participation to health. We advocate that microcredit and other potential pro-health PAS be included among the range of interventions considered by public health researchers in improving the health of the poor.

Driving the global public health research agenda forward by promoting the participation of students and new researchers: perspectives from Quebec.

OBJECTIVES: Current trends suggest a movement towards driving forward a global health research agenda in Canada in order to redress global health research inequalities. In this paper, we explore how to promote the participation of students and new researchers in global health in Quebec. To accomplish this, we undertook a study in order to: 1) document the state of teaching and research activities in global health in Quebec and 2) obtain the point of view of various actors on conducting global health research in the Quebec context. METHODS: Quantitative and qualitative data were collected through specialized grids and a documentation review (5 major universities), surveys (n=25), individual interviews (n=9), and two convened workshops (n=79). RESULTS: We identified 27 courses with global health content, 36 researchers in Quebec working primarily on global health issues, and 76 global health research projects implemented over the past 5 years. A number of threats and opportunities were reported with regards to engaging in global health research activities, as were a number of strengths and weaknesses with respect to the teaching and research environments in Quebec. CONCLUSION: There appears to be a relatively strong and growing presence of global health in Quebec universities--although the situation varies across institutions--with room for expansion. This trend is partly attributed to an increase in federal funding for and a growing awareness and profile of global health research activities since 2001 and to a growing expertise in global health research in the province. Students and new researchers, however, continue to face multiple challenges requiring special attention and targeted investment. We conclude with a set of recommendations for key stakeholders.

Healthy public policy in poor countries: tackling macro-economic policies

Large segments of the population in poor countries continue to suffer from a high level of unmet health needs, requiring macro-level, broad-based interventions. Healthy public policy, a key health promotion strategy, aims to put health on the agenda of policy makers across sectors and levels of government. Macro-economic policy in developing countries has thus far not adequately captured the attention of health promotion researchers. This paper argues that healthy public policy should not only be an objective in rich countries, but also in poor countries. This paper takes up this issue by reviewing the main macro-economic aid programs offered by international financial institutions as a response to economic crises and unmanageable debt burdens. Although health promotion researchers were largely absent during a key debate on structural adjustment programs and health during the 1980s and 1990s, the international macro-economic policy tool currently in play offers a new opportunity to participate in assessing these policies, ensuring new forms of macro-economic policy interventions do not simply reproduce patterns of (neoliberal) economics-dominated development policy. (AU)

Healthy public policy in poor countries: tackling macro-economic policies

Large segments of the population in poor countries continue to suffer from a high level of unmet health needs, requiring macro-level, broad-based interventions. Healthy public policy, a key health promotion strategy, aims to put health on the agenda of policy makers across sectors and levels of government. Macro-economic policy in developing countries has thus far not adequately captured the attention of health promotion researchers. This paper argues that healthy public policy should not only be an objective in rich countries, but also in poor countries. This paper takes up this issue by reviewing the main macro-economic aid programs offered by international financial institutions as a response to economic crises and unmanageable debt burdens. Although health promotion researchers were largely absent during a key debate on structural adjustment programs and health during the 1980s and 1990s, the international macro-economic policy tool currently in play offers a new opportunity to participate in assessing these policies, ensuring new forms of macro-economic policy interventions do not simply reproduce patterns of (neoliberal) economics-dominated development policy. (AU)

Healthy public policy in poor countries: tackling macro-economic policies.

Large segments of the population in poor countries continue to suffer from a high level of unmet health needs, requiring macro-level, broad-based interventions. Healthy public policy, a key health promotion strategy, aims to put health on the agenda of policy makers across sectors and levels of government. Macro-economic policy in developing countries has thus far not adequately captured the attention of health promotion researchers. This paper argues that healthy public policy should not only be an objective in rich countries, but also in poor countries. This paper takes up this issue by reviewing the main macro-economic aid programs offered by international financial institutions as a response to economic crises and unmanageable debt burdens. Although health promotion researchers were largely absent during a key debate on structural adjustment programs and health during the 1980s and 1990s, the international macro-economic policy tool currently in play offers a new opportunity to participate in assessing these policies, ensuring new forms of macro-economic policy interventions do not simply reproduce patterns of (neoliberal) economics-dominated development policy.

Women's health in a rural community in Kerala, India: do caste and socioeconomic position matter?

OBJECTIVES: To examine the social patterning of women's self-reported health status in India and the validity of the two hypotheses: (1) low caste and lower socioeconomic position is associated with worse reported health status, and (2) associations between socioeconomic position and reported health status vary across castes. DESIGN: Cross-sectional household survey, age-adjusted percentages and odds ratios, and multilevel multinomial logistic regression models were used for analysis. SETTING: A panchayat (territorial decentralised unit) in Kerala, India, in 2003. PARTICIPANTS: 4196 non-elderly women. OUTCOME MEASURES: Self-perceived health status and reported limitations in activities in daily living. RESULTS: Women from lower castes (scheduled castes/scheduled tribes (SC/ST) and other backward castes (OBC) reported a higher prevalence of poor health than women from forward castes. Socioeconomic inequalities were observed in health regardless of the indicators, education, women's employment status or household landholdings. The multilevel multinomial models indicate that the associations between socioeconomic indicators and health vary across caste. Among SC/ST and OBC women, the influence of socioeconomic variables led to a "magnifying" effect, whereas among forward caste women, a "buffering" effect was found. Among lower caste women, the associations between socioeconomic factors and self-assessed health are graded; the associations are strongest when comparing the lowest and highest ratings of health. CONCLUSIONS: Even in a relatively egalitarian state in India, there are caste and socioeconomic inequalities in women's health. Implementing interventions that concomitantly deal with caste and socioeconomic disparities will likely produce more equitable results than targeting either type of inequality in isolation.