More Equitable Nutrition and Health within Inequitable Societies

You can -as individuals- come to the will and intent to change underlying structural inequalities in society either from a primarily ethical or political process. In terms of equity, the bottom-up political process (in which commitments are needed beyond ethics)  looks preferable in that it better accommodates and represents the perceptions of needed development actions as seen from the perspective of development’s beneficiaries. In this approach, beneficiaries are clearly the protagonists of the process; the process is mostly politically motivated and assigns a key role to ‘social activists and political advocates’ who are to advance the cascading process 

By Claudio Schuftan*

Ho Chi Minh City,

Making Nutrition and Health More Equitable within Inequitable Societies 


I would like to think that you -as me- often ask yourself what we could all do better to achieve greater equity in what we do given that we most often work in countries with appalling social inequities. Allow me to share with you some of my thoughts on this.

I see our role in helping put in place the needed social processes and mechanisms that will drive sustainable policies in health and nutrition as being inseparable from us helping to re-establish a will and intent to change underlying structural inequalities in society. To achieve the latter, you can -as individuals- come to this will from either of 2 backgrounds: you can either come to it from a primarily ethical or from a political motivation.

These two motivational approaches that can drive us to become more involved in lessening social inequities represent, not packages of universal solutions, but rather paths to follow to get things that need to be done done, and the latter by whom and with whom (and against whom).

Living as we do in a mean, unfair and selfish world, I see the challenge we face as being one to graduate from the first into the second approach. Let me explain why.


As is true for slavery, there are ethical limits to tolerating extreme poverty

The growing new development ethics that calls for working with the poor as protagonists and not merely as recipients has, so far, itself unfortunately remained mostly a top-down approach. It represents mostly the view of academicians, of intellectuals, of church leaders, of international bureaucrats and of a few politicians (mostly in the opposition). Beneficiaries have remained mostly passive in this approach, merely being counted as the ‘object’ of the process. This ethics-led process is mostly ethically motivated and assigns a key role to ‘moral advocates’ who are to advance the following cascading process:

– NEEDS (Entails assessing needs requiring fulfillment using
 “objective”(?) field research techniques)
 – ENTITLEMENTS (Entails granting selected identified needs the status of
 entitlements to be honored by society)
 – RIGHTS (Entails translating accepted entitlements into actual rights)*
 – LAWS (Entails delegating to members of Parliament the
 legitimization of selected rights by promulgating them
 into laws)
 – LAW ENFORCEMENT (Entails assuring/securing that the laws get
 enforced by government institutions)**
 * : Promoting these rights is not, by itself, a progressive political
 **: Often very weak or non-existent and without the people getting involved
 directly in it.

The inherent weakness of this process is that to have rights ultimately respected, someone other than the poor takes the responsibility at each step to steer the process from entitlement to enforcement.


This more bottom-up political approach (in which commitments are needed beyond ethics) better accommodates and represents the perceptions of needed development actions as seen from the perspective of development’s beneficiaries. In this approach, beneficiaries are clearly the protagonists of the process; the process is mostly politically motivated and assigns a key role to ‘social activists and political advocates’ who are to advance the following cascading process:

– FELT NEEDS (As freely and spontaneously expressed by organized
 [Consciousness raising]
 – CONCRETE DEMANDS (Felt needs are articulated into concrete
 demands each tackling perceived causes)
 [Social learning]
 – CLAIMS/EFFECTIVE DEMANDS (Based on concrete demands, people
 make claims* and exert an effective
 [Social Mobilization/Empowerment]
 [Acquisition of Social Power]
 – ORGANIZED PEOPLE’S ACTIONS (Initial mobilization of own and
 other available resources)
 [Gains in self-confidence]
DE-FACTO EXERCISE OF POWER (Within or challenging the law;

bringing in, using and progressively
 controlling needed external resources)
 [Acquisition of Political Power]
 – CONSOLIDATION OF NEW POWER (Coalition building)
 [Leads to new felt needs and the cycle restarts]
 * : Claims correspond to entitlements in the previous diagram.
 **: When people are willing to invest their own resources to fulfill
 their felt needs.

Although the ethically and politically led approaches, as simplified in these two diagrams, represent different paths, both can contribute -through their own merits- to sustainable changes in the health and nutrition of the poor. The two approaches complement each other, but would be even more synergistic if the ethically led process gets more proactive civil society inputs and gets more politically savvy.

It is in the realm of the second diagram that I see us ever getting a chance to influence the choice of needed investments in health and nutrition, as well as influencing the redistributive and social protection measures/priorities that will concomitantly address the poverty underlying the ill-health and malnutrition we (as professionals) are left to deal with.

It is in the realm of the second diagram as well -with the added strength coming from an organized community- that I see us ever  effectively influencing how the public sector allocates its resources and chooses geographic/socioeconomic/ethnic targets, and how, in the process, the government favors programs that are under strong community control.

Finally, it is also in the realm of the second diagram that I see us succeeding in re-establishing a will and an intent to change structural inequalities underlying ill-health and malnutrition; our strength will come from building the new constituencies that do have a vested interest in pushing for the
unpostponable changes in the system that basically reproduces the existing structural inequalities and determines the parameters within which we (as professionals) are “allowed” to intervene.


*Short Bio

Claudio Schuftan has worked extensively at global level (especially in Africa and Asia) in fields such as Public Health including, Strengthening Management of Health Systems and Health Policy Formulation, Public Health Nutrition, Primary Health Care; Maternal and Child Health Care, Health Management Information Systems, Human Resources for Health, Health Project Design, Health in SWAPs, District Health Management, Health and Human Rights Capacity Building, Community Health, Health Promotion, Health governance, Health Sector Reform and Gender Issues. Dr Schuftan has significant monitoring and evaluation experience in these fields. Apart from sector and joint evaluations for various donors,he has monitored EU projects mainly in the fields of health and nutrition especially since the establishment of the ROM initiative in 2001. 

Dr. Schuftan has worked on the drafting of national plans of action in Cameroon, Kenya and Vietnam and has carried out in-depth situation analyses including access to health and right to health issues. He has prepared health investment plans and facilitated numerous training workshops. He has also written numerous training manuals. As senior adviser in the MOHs in Nairobi and in Hanoi he was in charge of operational planning at both central and local levels and contributed to SWAP-related work in one province in Vietnam. The same was done in Bangladesh. He has closely worked with concerned government agencies including public finance institutions and human rights committees.

By training, Dr Schuftan is a Medical Doctor and Pediatrician with a degree of the Universidad de Chile in Santiago and holds a post-graduate diploma in Food and Nutrition Planning from the Massachusetts Institute of Technology (MIT) in the US. He is a US, Chilean and German national and resides in Vietnam since 1995 (first Hanoi and then in Ho Chi Min City since 2003). He is the author of over 85 scholarly papers published in refereed journals.