Experts attack shift in global health strategy

The principles of primary health care to provide health services for all (irrespective of whether the patient can pay) have guided global and national health policies. But they are under threat from a dramatic change in health strategies, and this may cause a serious deterioration in people's health worldwide.

By Martin Khor

SILENTLY, almost unnoticed by the world public, there has been a drastic shift in global health strategy in recent years away from the principle of state responsibility for providing health care for all people. Instead, in many countries, the public health budget has been cut, health-related fees have shot up, and the health situation, especially of the poor, has deteriorated. Problems such as malnutrition and child deaths and the resurgence of cholera, tuberculosis, malaria, and plague will worsen if present trends in health policy continue.

This sober message emerged from a Health Strategy Consultative Meeting held in Penang in late-1994. The meeting, organised jointly by the International Peoples' Health Council and the People's Health Network, was attended by 20 health professionals and experts, and leaders of community-based health groups and non-governmental organisations from South Africa, Mexico, Palestine, Nicaragua, the Philippines, Malaysia, the United Kingdom, Australia and the United States.

David Werner, author of Where There Is No Doctor, the renowned and best-selling primer on community-based health practice, is very clear on why the public should be worried about the shift in global and national health strategies.

Werner, who works with the US-based Healthwrights group and is a consultant for the World Health Organisation, recalled how the concept of primary health care had been adopted by virtually all governments at the landmark 1978 WHO-UNICEF global health conference that endorsed the Alma Alta Declaration (so named after the town where the Conference was held). To advance toward 'Health for All by the year 2000', the Declaration promoted the principles that all people are entitled to basic health rights and that society (and thus government) has a responsibility to ensure that the people's health needs are met, regardless of gender, race, class, relative ability or disability. The declaration's centrepiece was primary health care, a comprehensive strategy that includes an equitable, consumer-centred approach to health services and also addresses underlying social factors that influence health.

It called for health ministries and health workers to be accountable to the common people, and social gurantees to ensure that basic needs (including food) of all people are met.

More distant

'Unhappily, these high expectations have not been met,' said Werner. 'Today it is painfully evident that the goal of Health For All is growing more distant not just for the poor but for humanity.' In the 1980s a disturbing trend emerged: while child mortality rates dropped, undernutrition and morbidity rates rose. In the late l980s and early l990s, the decline in child mortality rates slowed or halted and in many countries (especially in Africa) child mortality is now rising.

According to Werner, three factors have undermined primary health care. Firstly, instead of adopting a comprehensive health and social programme as envisaged, UNICEF compromised (due to a funds shortage) and opted for selective primary health care aimed at reducing child mortality through selected technological interventions, particularly oral rehydration therapy (ORT) and immunisation.

These programmes were helpful but were of limited success and are proving difficult to sustain especially in view of economic recession. Werner said that ORT usage and immunisation coverage have recently declined significantly in many countries. In the ORT programme, the emphasis was on selling people manufactured packets of oral rehydration salts rather than teaching them how to use inexpensive family-prepared 'home fluids'. The poor find it increasingly hard to have access to these salt packets: some families spend a fourth of their daily income for a single packet.

The second setback to primary health care was the introduction in the 1980s of structural adjustment programmes (SAPs) imposed on indebted Third World countries by the World Bank and International Monetary Fund as a condition for debt rescheduling.

Policies under SAPs include cutbacks in public spending, reducing government deficits by charging fees for health and other social services (which had previously been free), freezing wages and freeing prices, privatisation and public sector retrenchments.

'These policies hit the poor hardest,' said Werner. 'Budgets for so-called non-productive government activities such as health, education and food subsidies were ruthlessly slashed. Public hospitals and health centres were sold to the private sector, thus pricing their services out of the reach of the poor. Falling real wages, food scarcity and growing unemployment pushed low-income families into worsening poverty.'

Overwhelming evidence

Werner told the meeting there was overwhelming evidence that structural adjustment has caused a major set-back in world health. 'In many countries, improvements in health have slowed down or stopped since the mid-1980s and even more so since the beginning of the 1990s. In some countries, rates of undernutrition, tuberculosis, cholera, sexually transmitted diseases, plague and other indicators of deteriorating conditions, have been drastically increasing.'

Werner is especially angry at the 'user-financing and cost-recovery' principles introduced, together with privatisation of public health services, where people are asked to pay for medicines and treatment to recover the costs.

Where cost-recovery is introduced, use of health centres by high-risk groups has dropped. In Kenya, for example, the introduction of user fees at a centre for sexually transmitted diseases caused a sharp decline in attendance and an increase in untreated STDs in the population.

Cost-recovery has supplanted the previous principle of the responsibility of the state to provide health care for all. For Werner, this throws up disturbing social and ethical implications. 'It represents a retreat from progressive taxation, whereby society takes from the more fortunate to benefit the less fortunate, in a sense of fairness and sharing.

'When decision-makers inflict disadvantaged and undernourished people with an increased portion of health-related costs, this is a great step backwards. It means that for those in greatest need, health care is no longer a basic right.'

This scenario is made even gloomier by a third factor which Werner said has 'put the nail in the coffin of the Alma Ata Declaration'. He was referring to the increasing role of the World Bank in global health policy planning, based on the same philosophy as structural adjustment.

The Bank's sectoral health policy is spelled out in its World Development Report 1993. 'Under the guise of promoting an equitable, cost-effective, decentralised and country-appropriate health system, the World Bank's key recommendations spring from the same sort of structural adjustment paradigm that has worsened poverty and further jeopardised the health of the world's neediest people,' said Werner.

The Bank's three-pronged health approach for governments is to: foster an enabling environment for households to improve health; improve government spending in health; and promote diversity and competition in health services.

Behind the nice Bank rhetoric, Werner has the following interpretation:

* 'Foster an enabling environment' means requiring disadvantaged families to cover the costs of their own health, in other words fee for service and cost recovery through user financing or putting the burden of health costs on the shoulders of the poor.

* 'Improve government spending on health' means trimming government spending by reducing services from comprehensive coverage to a narrowly selective, cost-effective approach, or a new brand of selective primary health care.

* 'Promote diversity and competition' means turning over to private doctors and businesses most of those government services that used to provide free or subsidised care to the poor. This implies privatisation of most medical and health services, thus pricing many medical interventions beyond the reach of those in greatest need.

According to Werner: 'Many health groups fear the Bank will impose its recommendations on those poor countries that can least afford to implement them. What makes the new health strategy especially dangerous is that the Bank, with its enormous money-lending capacity, can force poor countries to accept its blueprint by tying it to loans.'

Werner's concerns were broadly shared by other participants. According to a leading health expert and organiser in India, Dr Mira Shiva of the People's Health Network, structural adjustment in India has led to increasing food prices and unemployment, causing a deterioration in health. There is also a significant cut in the government's health budget, and the World Bank has stepped into the financial vacuum with new loans in the health sector.

'The problem is that with one hand the Bank's policies are taking away the health services the government used to provide to the needy, and with another hand the Bank is giving money for health on a loan basis to be repaid,' said Dr Mira. 'Thus the strategy of providing public health on the basis of need is being replaced by a new strategy of providing health on the basis of cost recovery, in other words medical care would be available only to those who can afford to pay. And because of structural adjustment, there are more people who won't be able to pay.'

Direct and indirect factors

Prof. David Sanders, director of the Public Health Programme in the University of Western Cape, South Africa, has conducted extensive studies over the past four years on the impact of structural adjustment on health. He told the meeting that SAPs affect health indirectly (through a decline in the economy generally and changes in other sectors such as education) and directly (through policy changes in the health sector).

For example, in Zimbabwe, where he has done an in-depth case study, health status has been affected by factors outside the health sector such as a decline in real wages, the removal of food subsidies and fees or levies imposed on schools. Within the health sector itself, there have been budget cuts, resulting in a big reduction of mobile health clinics and services (resulting for instance in a fall in child immunisation), lack of maintenance of medical equipment and hospital buildings, reduced supply of medicines and increased user charges (resulting in a decline in utilisation of services).

Dr David Legge from the Public Health Association Australia, and a research fellow at the Australian National University, also presented a detailed critique of the World Bank's sectoral health approach. He said there was a serious methodological bias in the Bank's analysis and in its calculations of 'cost-effectiveness' for different kinds of health policies.

'The Bank's approach implicitly emphasises the value of the market place and discounts the values and criteria which families may have, on what is important for their lives and their health priorities,' said Legge.

Dr Legge gave the example of grandmothers who are much valued for their role in family health care and for their intrinsic selves, but whose value is discounted because a higher value in the cost-effective calculations is placed on people in the economically active age group.

'The Bank's report also proposes a very limited role for government in health care. Governments are depicted as inevitably inefficient. In contrast, the private sector is depicted as efficient and its role is strongly promoted. This is a very biased and one-sided view of the strengths and weaknesses of the public and private sectors and what their roles should be.' The participants will be drawing up a statement expressing their concerns and offering alternatives to the present strategies that have become dominant.

'We hope to alert governments, health policy makers, health workers, the medical profession and NGOs on the dangerous shift in global health strategy,' said Maria Hamlin Zuniga, coordinator of the International Peoples' Health Council. 'We need them all to reassert the principles of primary health care, and of Health for All that was agreed to by the governments in l978. Otherwise we will see a continuing deterioration in health, which will affect not only the poor, but all of us.'

Martin Khor is the Director of Third World Network.