Health hazard / USER FEES
Whatever happened to 'Health for All'? David Werner
traces the fate of a revolution that could still happen.
The Alma Ata Declaration, Primary Health Care, back in 1978 produced a lot of optimism about working towards ‘Health for All by the Year 2000’. Health was upheld as a basic human right. Primary Health Care (PHC) was to have a far-reaching, even liberating, potential. It embraced the World Health Organization’s broad definition of health as ‘complete physical, mental and social well-being’. It mandated universal availability of basic health services, with special concern for those in greatest need. To overcome the underlying human-made causes of ill health, it called for working toward a new economic order based on equity. Needless to say, such a comprehensive, potentially revolutionary approach was received less than enthusiastically by those with power and privilege to defend. It was not long after the world’s health ministers signed on at Alma Ata that the cries of ‘unrealistic’ began to be heard. In 1979, a paper out of the Johns Hopkins School of Public Health insisted that Comprehensive PHC was too all-encompassing and a more limited selection of priority health problems affecting high-risk groups was needed. Low-cost, easily implemented technologies were recommended. This was the beginning of the end for the broad, social-justice approach to primary healthcare. Throughout the Third World, PHC was stripped of its social-change-seeking content and diluted into ‘Selective Primary Health Care’ (SPHC). Its unifying focus on equity and community participation were replaced by a few quick-fix technologies. The dream of changing the world was reduced to the doctrine of changing behaviour.
Even UNICEF, once a strong proponent of Comprehensive PHC, caved in to US State Department accusations that it was ‘too political’, and jumped on the Selective PHC bandwagon. It promoted two ‘simple, lifesaving technologies’ – Immunization and ‘ORT’ – which became the ‘twin engines’ of UNICEF’s Child Survival Revolution. (ORT, or Oral Rehydration Therapy, involves giving lots of fluids to children with diarrhea, to prevent death from dehydration.) Their global campaign did lower child mortality. But the question remains: Has it improved children’s quality of life? In 1991, UNICEF reported that malnutrition contributed to 35 per cent of children’s deaths. By 1996 this had jumped to 55 per cent. According to World Watch, more children are malnourished today than ever before! And despite recent record-breaking economic growth, one in five of the world’s children go hungry. Hungry children are not healthy. Their minds and bodies do not develop fully. A resurgence has occurred of ‘diseases of squalor’ such as cholera, tuberculosis and plague. In a world of plenty, countless children remain sick with hunger. What happened to Health for All?
Make the poor pay
One of the most punishing measures was a ‘cost recovery’ strategy that included ‘user fees’. Where free healthcare and essential medicines were once provided, poor people were now required to pay. Studies in several countries show user fees decrease utilization of medical services and increase child mortality, sexually transmitted disease and tuberculosis. In Ghana, one of the Bank’s high-profile success stories, economic growth was accompanied by user fees in rural clinics that contributed to a doubling of child mortality between 1983 and 1993.
A tragic example of ‘cost recovery’ is the impact on Oral Rehydration Therapy (ORT). Next to pneumonia, diarrhea is the world’s biggest killer of children (it still kills over three million a year). Nearly all who die from diarrhea are malnourished; well-fed children usually recover. To reduce death from diarrhea, UNICEF promoted wide distribution of ORS – factory-produced aluminum envelopes of Oral Rehydration Salts to be mixed with a litre of clean water. Although these packets were relatively costly and created a dependency, this was thought safer than teaching mothers to prepare simple and cheap homemade rehydration drinks. At first the poor did not suffer these costs, since the ORS packets were distributed free. But when Structural Adjustment policies of ‘cost recovery’ began to bite, health ministries were forced to charge families. While $0.10 for an ORS packet may seem little, it cuts deeply into the food budget of a family in Bangladesh earning only $0.20 a day. For the fifth of humanity that lives on less than a dollar a day spending limited food money on ORS packets may be counterproductive. Even if ORS saves a child’s life today, its cost may cause more hunger and risk of death tomorrow.
Today ORS has become big business. With its commercialization, competitors produce many different forms, packages and flavours, to be mixed with a cup, half-litre, or litre of water. For mothers who cannot read, this can be confusing, even dangerous. ORS mixed in too little water can increase dehydration and risk of death.
Let the Bank dictate
Prong one: ‘Foster an enabling environment for families to improve health.’
Translation: Families should pay for their healthcare. To enable this, foster economic growth through the free-market system. With policies that make the rich richer, some of the wealth is supposed to trickle down to the poor, though history repeatedly shows otherwise.
Prong two: ‘Improve government spending on health.’
Translation: Trim government spending by reducing service provision to a few problem-specific programmes selected for cost effectiveness. Make poor people pay for their health care, though history shows this reduces health.
Prong three: ‘Facilitate greater diversity and competition in the provision of health services.’
Translation: Turn over to private profit-making doctors and businesses most government services that used to be free or subsidized for the poor. The World Bank points to the US health system as a model for the Third World, even though US healthcare is the most costly and least effective in the world’s 17 wealthiest nations. The state should invest only in cost-effective health measures that contribute to ‘the economy’ – that make the rich richer.
To figure out which health measures merit public support, the Bank invented DALYs, or ‘Disability Adjusted Life Years’. A DALY assigns different values to probable years of productive life at different ages. People between age 20 and 40 have high value because of their greater potential for contributing to the economy. Investing in their health saves more DALYs.
By contrast, babies, old folks and disabled people have little value. They don’t contribute economically, so few DALYs are saved by addressing their needs. The humane principle of assisting those in greatest need is obsolete. This is just a market-friendly version of Selective Primary Health Care, replete with privatization and user-financed cost recovery. It glosses over the real determinants of health. The privatization of high-tech medical services, slashed budgets and the introduction of user fees add up to only one thing: health is no longer a human right.
Signs of hope
In December 2000, the People’s Health Assembly (PHA) held a groundbreaking meeting in Bangladesh. Over 600 participants represented progressive community heath movements, NGOs and grassroots organizations from 100 countries. Where the politicians have failed, the grassroots may yet succeed.