User fees blamed for cholera outbreak in South Africa

by Lean Ka-Min

Geneva, 26 Oct 2000 - Unable to pay for the water supplied by the local water board, people in the KwaZulu-Natal region of South Africa began using polluted river water, resulting in a cholera outbreak which to date has claimed 32 lives.

This incident serves to highlight the damaging effects of fiscal balancing policies promoted by the likes of the International Monetary Fund and World Bank in borrower countries and which have entailed the imposition of user fees for the provision of basic services as governments are exhorted to balance their budgets.

According to media reports and information posted on NGO bulletin boards, the cholera epidemic in KwaZulu-Natal can be attributed to water supply cuts to people who were too poor to pay their accounts.  This in turn drove residents to use polluted river water, triggering an outbreak which has so far hit 3,711 people (as of 24 October).

Water had been provided free of charge in the Mpendle area in KwaZulu-Natal from the early 1980s after tap water supplies were laid on by the apartheid government following a severe drought.

However, just as supplies were being extended in the area, the local water board began charging for water, in line with implementing the policy of a cost recovery programme. Recovering costs for community services is a key component of the South African government’s much-criticized macroeconomic policy, GEAR.

Indeed, the country’s Water Affairs and Forestry Ministry has admitted the “absolute” truth that people were too poor to pay for water, resulting in supplies being cut and their having to resort to using river water. This came on the heels of a statement by public service union Nehawu which drew the link between the cholera outbreak and the GEAR strategy.

The 32 lives lost in KwaZulu-Natal are only the latest in a long line of casualties incurred as a result of the charging of user fees for basic services. These fees are imposed under IMF/World Bank-enforced policy programmes in the developing world designed to balance government budgets.

The Bretton Woods institutions have lent tens of billions of dollars to about half the world’s nations, in return for which the borrowers, financially troubled developing countries, must agree to meet, among other conditionalities, specified fiscal deficit targets.

The cost of such measures has been largely borne by the poor in the respective countries.

Education fees - even those as low as $7 a year in such countries as Tanzania - discourage poor children, especially girls, from attending school, while fees at health clinics deter sick people from seeking treatment, according to World Bank and outside research.

Conversely, after $8 annual school fees were dropped in Uganda in 1997, the number of school-going children doubled immediately, according to a bank study. A similar outcome had been noted in nearby Malawi two years earlier.

“All we know from experience is that user fees are a deterrent to universal education and universal health,” says Stephen Browne, director of poverty programmes at the UNDP. “What we are starting to see now is that access to basic social services is fundamental to development and a basic human right.”

A 1998 internal review of the Bank’s health lending found that three-quarters of projects in sub-Saharan Africa included the establishment or expansion of user fees.

The World Bank vice-president Eduardo Doryan says “we are moving in the direction” of eliminating the imposition of fees for basic services from all loan programmes.

This apparent policy reversal by the Bank comes as it faces increasing pressure from various quarters to make its policies more sensitive to the poor.

[As a result of campaigning by a large coalition of churches, NGOs and others in the anti-debt campaign, the US House of Representatives has adopted a Foreign aid bill, which includes a requirement that the US representative on the IMF and Bank boards oppose any effort by those agencies to condition loans to countries on their adoption of user fees for basic health care or education services.]

Lest anti-poverty groups start celebrating the dawn of a wholesale change of heart within the neo-liberal establishment, the Bank’s sister organization, the IMF, on its part, says it is not considering the revocation of fee requirements in its programmes.

“When you get into the fiscal mix, a lot of things are necessary,” declared IMF spokesperson William Murray.

World Bank chief economist is also against an outright ban on the charges. “Blanket solutions are unwise,” he said at a conference in the week of 23 October.

While advocacy groups acknowledge that doing away with user fees will not by itself solve the entrenched problems of poor health and low educational attainment in the world’s poorest countries, it would remove one prominent barrier lining the road to development.

Says Joanne Carter, who has tracked the imposition of these fees for the anti-poverty group Results, “The intent of these fees was sustainability of funding, but the outcome has been exclusion.” Indeed, as the KwaZulu-Natal incident has so tragically demonstrated, user fees can exact a price that extends beyond exclusion.

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