Health hazard / USER FEES

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
The next major setback for Primary Health Care was the Structural Adjustment Programmes (SAPs) pushed by the World Bank and International Monetary Fund (IMF). These ‘austerity measures’ are part of the demise of collective social responsibility typical of economic globalization. The SAPs were designed to make sure poor countries kept servicing their huge national debts to Northern banks. The Bank and the Fund made ‘bailout loans’ to indebted countries on condition they adjust their economies to free up money for debt payment. This meant slashing health and education budgets. Low-income and rural health centres were shut down or paralyzed due to lack of medicines. Public hospitals were privatized, making their services inaccessible to the poor. Food subsidies and welfare programmes were aborted.

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
Since the mid-1980s the World Bank has become directly involved in health-policy planning in the South. The Bank’s health spending is now three times the entire budget of the World Health Organization. It is an ominous sign when a giant financial institution with such strong ties to big business bullies its way into healthcare. Yet with its enormous money- lending capacity, the Bank can force its health blueprint on poor countries. The World Bank’s 1993 World Development Report ‘Investing in Health’ spells out its agenda. Despite progressive-sounding language about ‘empowerment’ and ‘health for all’, this report is a masterpiece of disinformation. ‘Investing in Health’ proposes a ‘three-pronged policy approach to health reform’ which can ‘save millions of lives and billions of dollars’. At face value, each prong sounds reasonable, even moderately progressive. But the fine print reveals a neoliberal agenda:

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
More and more people are beginning to wake up to the fact that the unregulated concentration of wealth and power threatens not only their own health but the well-being of all of humanity and the ecological balance of the planet. The protest against the unhealthy practices of the World Bank – seen from Seattle to Prague – recently achieved a coup within the US Congress. On 3 August 2000, the House of Representatives passed a measure pressuring the World Bank and IMF to stop requiring user fees for basic health services and primary education in the poor countries of the South. This measure was spearheaded by Jesse Jackson Jr, an outspoken advocate of debt cancellation and economic justice. Spokespersons from grass roots coalitions, including ‘50 Years is Enough’, provided evidence from diverse countries. They showed that ‘user fees’ have increased illness, suffering and death. This is a landmark event! The US Government is the top funder of Bank and Fund, and long a staunch ally of their draconian adjustment policies. For the first time the US Congress is requiring positive changes. It shows that even in our lopsided and endangered world there is room for hope. When people take collective action and demand a voice, little by little they can create a healthier, more caring environment. Perhaps a strategy to pursue Health for All can still be caringly and effectively introduced.

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.

has spent 30 years working in the mountains of western Mexico helping poor farming families protect their health and rights. Among his many publications are Where There Is No Doctor and most recently The Politics of Primary Health Care and Child Survival. [email protected]