In the headlong rush to embrace market-friendly solutions, our governments are letting go of their responsibilities for public health. The Health for All slogan is but an embarrassing reminder of idealistic days long past.
The Man in Black on the flight to Dhaka could have been a photographer on his way to cover the People’s Health Assembly. After all, this meeting on globalisation, poverty and health had attracted worldwide attention and the international press. As it turned out, the gentleman was an architect from Bangalore carrying designs for the Dhaka branch of the Madras-based Apollo Hospital chain, which has plans to nurse the Bangladeshi elite back to good health. Even as all over South Asia the well-to-do are beginning to access the best in medical care via the medium of organisations such as Apollo, the divide between the medical haves and public health have-nots, has begun to expand rapidly.
That, indeed, was going to be the main subject of concern for the participants from 93 countries congregated at the village of Savar near Dhaka in the first week of December. The People’s Health Assembly was the culmination of a year-long international campaign against international economic policies which have inflated prices, increased unemployment, and heightened job insecurity and economic equality between and within nations. These processes have reduced the availability of food, social services and health care for the poor, and the immediate repercussions have been felt in the medical fitness of people, and their susceptibility to disease.
The choice of Bangladesh as the site for the conference was appropriate, for its story has been one of a step forward and two back when it comes to public health. Once famous as an inspirational David among Goliaths, thumbing its nose at the pharmaceutical giants and going the way it thought was right in drug policy, Bangladesh has come back to the fold of developing countries who do as they are told. In the not-too-distant past, during the regime of Hussain Mohammad Ershad, the community-based organisation, Gonoshasthaya Kendra, had helped formulate a national drug policy that resisted the pressures of multinationals and thwarted the dumping of inappropriate and dangerous drugs. A set of limited medicines of known efficacy was popularised, and the country became the toast of the public health fraternity worldwide.
Times have changed, and today Bangladesh is better known as the stomping ground of some pretty dubious health research, particularly on controversial contraceptives. In many ways, the country’s situation simply reflects the larger Subcontinent’s capitulation to the demands to international interests. According to one estimate presented by researcher Kamran Abassi, who has studied “the World Bank and world health”, 35 percent of the health sector funding in Bangladesh is coordinated by a consortium of 10 donors and aid agencies, headed by the Bank. The Bank’s lending is tied to the government implementing health policy ‘reforms’ which include cost recovery for government health services, and replacing public services with ngo and private sector services.
Those in government, academia and media, who should be concerned about such measures and their impact on public health, are not keeping watch. The average life expectancy at birth in Bangladesh is just about 55. Almost 20 percent of deaths are from typhoid; another 25 percent are from tetanus, TB and diarrhoeal infections. Simply and starkly, at least 45 percent of deaths in the country could be prevented with clean water, better nutrition and decent living conditions, coupled with access to simple health services. At the root of such dismal statistics is the sustained and systematic erosion of the concept of primary health care.
The People’s Health Assembly was convened to address these kinds of consequences emanating from the current health sector trends in developing countries. Through a combination of plenary sessions, concurrent workshops and testimonies, the Assembly presented a rich portrait of what is being done and undone in health care around the world, as well as the struggles of individuals and organisations to keep some space for public health in an increasingly hostile economic and political environment. At the end of five days, the assembly approved a People’s Health Charter on globalisation and people’s health, with a package of demands on people’s right to health through primary health care.
Good Health by 2000
Speaking at the Assembly was Halfdan Mahler, director general of the World Health Organisation in the 1970s. He recalled the build-up within the WHO of a movement for primary health care (PHC), which was what eventually led to the Alma Ata meeting of 1978. The Alma Ata Declaration was a historic document which explicitly linked ill health to poverty, inequality and lack of socio-economic development. It pointed out the need to address these underlying causes of illness as well as to provide health services for all as a matter of right.
As public health specialist Imrana Qadeer of Delhi’s Jawaharlal Nehru University (JNU) says, the Declaration’s call for “Health for All by the Year 2000” had identified primary health care “not as elimination of disease by targetted technological means alone but as a complex of strategies that determined people’s livelihood and quality of life”. However, even as the Declaration was being signed in the Kazhak capital, it came under attack from within the international health establishment. The concept of integrated primary health care was quickly replaced by a ‘selective PHC’ approach—a package of technological, ‘cost-effective’ solutions. Selective PHC, Dr Qadeer argues, ignores the fact that there are multiple political, social and economic determinants of health and disease. It also focuses on making the best use of scarce health resources without questioning the reasons for this scarcity.
This quick about-turn on primary health care, almost before the ink was dry on the 1978 Declaration, was no accident. Australian economist, David Legge notes that the forces controlling international trade have always been committed to a model of socio-economic development that runs contrary to the principles enunciated at Alma Ata. It is these forces, he argues, that are responsible for a widening ‘global health gap’. To cite just one instance, the ratio of age-specific death rates of developing to other countries has gone up steadily since 1950, indicating widening gaps in resources and access to health care.
Even as the WHO members committed themselves to primary health care, developing countries faced an extended economic crisis caused by the unfair economic trading system. This crisis forced developing countries to borrow extensively from multilateral lending institutions, and by the early 1980s, these countries were not in a position to service their debts. At this point, international financial institutions imposed Structural Adjustment Programmes on borrowing countries as a condition for further credit. The economic downturn had already pushed “Health for All” to the back of national agendas, and now the demands for structural adjustment cut into the already under-funded public health services. All problems were attributed to state-controlled planning and protectionism, and the suggested panacea was to join the world economy as a free marketeer. The new creditor-driven dispensation presided over the dismantling of the limited welfare establishments in developing countries. The impact was swift and ruthless, and the result is to be found today in the inadequacies of health care, among the sick and the dying, across the expanse of South Asia. The name of Alma Ata has begun to sound alien even to those greying practitioners and activists who attended the conference in 1978.
Globalising public health
The links between the much-vaunted opening up to the liberalised economy and the health-related impoverishment of the people can be graphically illustrated by studying the trends in the industrialised Indian state of Maharashtra, across the face of the Subcontinent from Bangladesh. In January 2001, a two-day special cabinet meeting unanimously approved a new industrial policy and proposed changes to labour legislation. Under the new policy, factories with less than 300 workers can shut down without a by-your-leave. Waste disposal agencies, canteens, security agencies, gardens, courier firms and 100 percent export-oriented units are exempted from the provisions of the Contract Labour (Prevention and Abolition) Act. The chief minister holds that the changes in labour legislation and the new industrial policy will help industrial production and improve the “work culture”.
Such policies led to the steady ‘informalisation’ of the workforce. Bombay labourers suddenly made ‘casual’, borrow money to have sick family members treated by private doctors in the slums. This seems a cheaper option to giving up a day’s wages to line up at the municipal hospital. In any case, these days, the government hospitals no longer provide free medicines. The patient’s families also believe that private doctors are doing them a favour by charging INR 30 for an injection, whereas it is more than likely that the intervention was both unnecessary and dangerous.
Health groups and unions in Bombay have long been protesting user fees in municipal hospitals, and making the poor pay for essential drugs and tests. But the state government is unmoved. Instead, in the belief that the city has no shortage of public facilities but needs yet another five-star hospital, in January, the Maharashtra government signed an agreement with Wockhardt Hospitals Ltd to run a super-specialty hospital on the premises within the grounds of the general hospital.
All this is in tune with the World Bank’s prescriptions, and the hakims at 1818 H Street in Washington DC must have been pleased. As Mahler noted, by 1993, the World Development Report Investing in Health, published by the Bank, had anointed the Bank as a substitute World Health Organisation, directly controlling health policy in developing countries. The package pushed by the Bank includes reduction in welfare, dismantling of public services, introduction of service charges in public institutions, and the promotion of the private and voluntary sectors. Yet, as survey after survey has shown, user charges for health services reduce usage, at the expense of people’s health.
After Zimbabwe introduced structural adjustment in 1990, even as per capita expenditure on health care fell by a third, the mortality rate of under-fives went from 101/1000 to 162/1000. In India, where structural adjustment was instituted in 1991, the 1998-99 National Family Health Survey found that infant mortality rates in the nine states surveyed, had gone up. In Guyana, notes Mohan Rao, a public health specialist at the JNU, “Throughout the 1980s and 1990s, malnutrition, child death rates, unemployment and poverty rose dramatically as result of the implementation of the SAP package.”
Another example of gains in public health being squandered is the Indian state of Kerala, with its health indicators comparable to those of developed countries. This achievement was the result of decades of work, but now the public health system is being starved of drugs and facilities. The state’s private sector grows uncontrollably, outpacing the public sector in personnel, hospital beds and with twice as many doctors, and much more sophisticated technology. B. Ekbal, an activist, says that with increasing health care costs and the progressive marginalisation of the poor, the Kerala model is drifting far from its much-vaunted roots and towards the American model. In the process, 40 million people are losing their health care coverage.
Across the Palk Strait, Sri Lanka’s success in opening its markets has similarly led to impoverishment of public health. Nimalka Fernando, secretary of the Movement for Inter-Racial Justice and Equality in Colombo, notes that Sri Lanka’s famed public health system had started to collapse immediately with the implementation of the 1977 structural adjustment package, which included increased privatisation and reduced social spending, a clampdown on trade unions, and the growth of free trade zones unencumbered by labour legislation. Food support for pregnant women is now a thing of the past; the mid-day meal programme for school has been discontinued. Due to lack of funding for spraying, there has been a resurgence of malaria. The incidence of babies of low birth-weight is on the rise, anaemia is widespread.
Health programmes promoted by the World Bank today are nothing more than a further refinement of ‘selective PHC’. The 1993 World Bank report proposed that poor countries provide only family planning, prevention of and treatment for a few infectious diseases, and immunisation for children. All other services could be provided by the private sector, it was said. Such interventions not only ignore the conditions in which these diseases exist, they promote a private sector that sees health care only as a source of profit.
A good example of this is the propagation of oral rehydration solutions in Nepal, says Sharad Onta, a Kathmandu public health activist. The prescription for diarrhoea, which is the main killer of Nepali children, is ofcourse, oral rehydration solutions. But the underlying cause is economic, the result of contaminated water supply compounded by poor nutrition. Besides the problems with policy focus, the concept of ORT is used by industry to exploit families through aggressive marketing of oral rehydration solutions.
Back to basics
The proponents of structural adjustment point to the fact that in many poor countries, the bulk of health expenditure is in the private sector and hence borne from personal resources. Such high private spending, they argue, indicates that people will and should pay for health services. But this arguments misses the fact that demand for health care is one of the most elastic, shaped not so much by the immediate consumer (the sick person) but the medical establishment which stands to gain at each instance. In countries like India, where 80 percent of hea-lth expenditure is privately incurred, the poor will reduce food intake in order to pay for health services. This will make them more vulnerable to disease. And indeed, studies suggest that health care is the second most important cause of indebtedness in India today.
What then lies ahead? The hundreds of participants at the Public Health Assembly outside Dhaka went away, at the very least, with a better understanding of the global processes which affect the life and health of the individual child, woman and man in the developing world. Within South Asia, which contains the bulk of the world’s poor and ailing, this understanding must now lead to activism for renewal of faith in primary health care, and away from the wide-eyed acceptance of market-led technological fixes to medical problems. The challenge of the moment is to confront the real sources of power, said James Obrinsky, former president of the medical relief organisation, Doctors without Borders (Medicine sans Frontiere). And this must be in a way that does not result in its premature co-opting.