HEALTH AND EQUITY - EFFECTING CHANGE
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HEALTH AND EQUITY - EFFECTING
CHANGE
A Workshop by FRCH-IIMB-HIVOS
2nd & 3rd August 2000
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Hivos Regional Office
Flat, No. 402, Eden Park
No. 20, Vittal Mallya Road
Bangalore 560 001
Telefax: 080-2210514/ 2270367
Email: hivos@hivos-india< org
Community Health Cell
Library and Documentation Unit
367, “Srinivasa Niiaya"
Jakkasandra 1st Main,
1st Block, Koramangala,
BANGALORE-560 034.
Phone : 5531518
HEALTH AND EQUITY-EFFECTING CHANGE
A FRCH-IIM(B)-HIVOS WORKSHOP
2nd - 3to AUGUST, 2000
IIM (BANGALORE)
The workshop on “Health and Equity- Effecting Change” is being jointly organised
by Hivos, FRCH and IIMB to be held on 2-3rd August 2000 at the Indian Institute of
Management, Bangalore. This meeting is being called at a time when several changes
are occurring globally- the rapid changes that globalisation has brought on to national
economies, the growing destitution of vulnerable populations in many countries and
the multiple burdens of ill health and poverty for the poor. For the many who have
been engaged in development work and who have indeed spent considerable time on
health issues of the poor, constructing on the field viable alternatives for the poor in
accessing health care, who have sensitised governments to respond more effectively
to the health needs of the marginalised or have acted as allies in the struggle for equal
care it has become a time for stock taking of matters as they stand and for assessing
the nature of the concerns, the contours of the crises and the responses that are
required.
This meeting will provide a platform for committed development practitioners with
common concerns but not necessarily with similar approaches to come together and
spend two days during which time ideas may be shared, presentations with unique
perceptions provided for mutual discussion and case studies across locations and
constituencies mutually understood. A tentative agenda is enclosed.
Agenda for Workshop on
Health and Equity-Effecting Change
A FRCH-HM(B)-Hivos Workshop
2nd and 3rd August, 2000
IIM (Bangalore)
2nd August 2000
08.45 a.m.
Registration
09.30 a.m.
Welcome - N.H. Antia, Hannah Pick and Gita Sen
- Introduction of Participants
Introduction Thematic Issues
The State and Civil Society: Meeting Health Needs,
Reaching Equity - Shobha Raghuram
Chair: N.H. Antia
10.30 a.m.
Coffee Break
11.00 a.m. - 01.00 p.m.
Public Health in India: Its Development and
Challenges
Equity and Health - N.H. Antia
Health Sector Changes and Health Equity in the 1990s
- Aditi Iyer and Gita Sen
The Karnataka Health and Equity: Report of the
Karnataka Task Force - H. Sudarshan
Chair: Debabar Banerjee
Discussion
01.00 - 02.00 p.m.
Lunch
02.00-04.00 p.m.
Group Discussions “Challenges on Effecting Change”
Group Discussions on
Medical Poverty Trap (The Problem and the
Recommendations)
Ritu Priya
World Bank and Impact of Bank’s Policies on
Health (The Problem and the Recommendations)Ravi Narayan
Privatisation of Health Care (The Problem and the
Recommendations)
People’s Health Assembly
Rapporteurs - Jamuna Ramakrishna, Thelma
Narayan, and Minda Groenwald
04.30 - 05.30 p.m.
Panel Presentation by Rapporteurs
Chair: Vimala Ramachandran
07.30 p.m.
Reception
3rd August 2000
09.00 a.m.
Civil Society Partnerships: Examples from the Field
Protecting Consumer’s Health in Developing Countries
- Debabar Banerjee
Health Financing: The State and Health Services
- Indira and Vinod Vyasulu
Discussion
Chair: Veena Shatrugna
10.45- 11.00 a.m.
Coffee Break
11.00-01.00 p.m.
Field Achievements in Health Care
FRCH - N.H. Antia
Women and Health - Elizabeth Vallikad
VGKK - H. Sudarshan
CINI
People’s Health Assembly
Chair: Amar Jesani
01.00-02.00 p.m.
Lunch
02.00 - 05.00p.m.
Health Care and Ethics - A Panel Discussion
- Medical Ethics and Human Rights - Amar Jesani
Between the Clinic and the Community
- Vijay Thakur
People’s Health Assembly
Ravi Narayan
Chair: H. Sudarshan and Thelma Narayan
Vote of Thanks FRCH, IIM (B) and Hivos
Tentative List of Invitees for the Workshop on
Health and Equity-Effecting Change
2nd - 3rd August, 2000
Organised by HIVOS, Gita Sen (IIMB), FRCH
Indian Institute of Management, Bangalore
Aditi Iyer
Indian Institute of Management (UM)
Bannerghatta Road
Bangalore 560 076
Ph. No. 6582450
Resi No. 3336030
E-mail, aditiyer@yahoo.com
Amar Jesani
310 Prabhu Darshan
31 S.S. Nagar
Amboli
Andheri (West)
Mumbai 400 058
E-mail, iesani@vsnl.com
Anitha .B.K
Research Fellow
Gender Studies Unit
National Institute of Advanced Studies
Indian Institute of Science Campus
Bangalore 560 012
Email anibk@nias.iisc.ernet.in
Basavaraj
People’s Health Assembly
Bharath Gyan Vikas Samithi
Old Chemical Engineering Building
Indian Institute of Science
Bangalore 560 012
Ph. No. 3600384
Email bgvs kar@hotmail.com
Bhargavi Nagaraja
304, Adarsh Nest
3rd Cross
C.R. Layout
J.P. Nagar 1st Phase
Bangalore 560 078
Ph. No. 6639411
Fax. No. 6648119
Email. bhargavi@giasbgO 1.vsnl,net,in
1
Debabar Banerjee
B-3, Panchsheel Enclave
New Delhi 110 017
Ph. No. 6490851, 6498538
E-mail. NHPP@bol.net.in
Elizabeth Vallikad
St. John’s Medical College and Hospital
Sarjapur Road
Bangalore 560 034
Ph. No. 5520777
Gita Sen
Indian Institute of Management (IIM)
Bannerghatta Road
Bangalore 560 076
Ph. No. 6582450
E-mail. gita@IIMB.ERNET.IN
Indira
TIDE
1st Floor, S.V. Complex
(Opp. Basavanagudi Police Station)
55, K.R. Road
Basavanagudi
Bangalore 560 004
Ph. No. 6671756
Fax. No. 6619391
Email. cbps@bgl.vsnl.net.in
Kalpana Viswanath
Coordinator
Jagori
C-54, NDSE Part II
New Delhi 110 049
Ph. No. 011 6257015
Res. Ph. No. 011 6199508
Fax. No. 011 6253629
Email, jagori@del3.vsnl.net.in
K.C. Basavaraj
MGRDSC TRUST
No.2879, II Floor
14th E Main, Sth E Cross
RPC Layout, Vijayanagar, 2nd Stage
Bangalore- 560 040
Ph. No. 3392175
2
Dr. K. S. Krishnaswamy
C 601, Adarsh Gardens
47th Cross,, Jayanagar 8th Block
Bangalore 560 082
Ph. No. 6651488
Minda Groenwald
Hivos Head Office
Raamweg 16
2519 HL Den Haag
The Netherlands
Ph. No. 0031 70 3765500
Mukta Banerjee
Programme Coordinator
The Hunger Project
202,KT 46,9th Cross
9th Main, Malleswaram
Bangalore
Ph. No. 3442879
Email, muktaban@yahoo.com
Neerajakshi
Voluntary Health Association of Karnataka (VHAK)
No. 60, Rajini Nilaya
2nd Cross, Gurumurthy Street
Ramakrishna Mutt Road
Ulsoor
Bangalore 560 008
Ph. No. 5546606
Email vhak@bgl.vsnl.net.in
N.H. Antia
Foundation for Research in Community
Health
84-A, R.G. Thadani Marg,
Worli Sea Face,
Mumbai 400 018
Tel: 4934989/4932876
Fax: 4932876, C/o. 2662735
E-mail, frchbom@bom2.vsnl.net. in
Nargis Mistry
Foundation for Research in Community
Health
84-A, R.G. Thadani Marg,
Worli Sea Face,
Mumbai 400 018
Tel: 4934989/4932876
Fax: 4932876, C/o. 2662735
E-mail. frchbom@bom2.vsnl.net.in
3
Padmini Swaminathan,
Madras Institute of Development Studies,
79, 2nd Main Road,
Gandhi Nagar, Adyar,
Madras - 600 020.
Ph. No. 412589/4412295/4419771
Email. padminis@mids.tn.nic.in
Pavalam/Gandhimathi
Campaign Against Sex Selective Abortion
11, Kamala 2nd Street
Chinna Chokkikulam
Madurai 625 002
Ph/Fax. No. 0452 530486
Email, sirdmdu@hotmail.com
Prema D
Khrist Niketan Dispensary
New Area, Gayat hr i Nagar
Sasaram
Rohtas District
Bihar 821 115
Ph. No. 06184 22078
Fax. No. 06184 22019
Priya Nanda
New Delhi
Ravi Narayan
Community Health Cell (CHC)
No. 369, Srinivasa Nilaya
Jakkasandra
1st Block, Koramangala
Bangalore 560 034
Ph. No. 5531518
Email, sochara@vsnl.com
Revathi Narayanan
State Programme Director
Mahila Samakhya Karnataka
No.68, 1st Cross, Und Main
HAL Hird Stage
J.B. Nagar
Bangalore 560 075
Ph. No. 5277471/5262988
Fax.No. 5297765
Ritu Priya
Centre for Social Medicine and Community Health
Jawaharlal Nehru University
New Delhi 110 017
E-mail, ritupriya@vsnl.com
4
Ruth Manorama/Shahtaj
NAWO
392, 11th Main
3rd Block
Jayanagar
Bangalore 560 011
Ph. No. 6630297
Sabu George
327, Prashanth Nagar
Medical College Post Office
Trivandrum 695 011
Samir Choudhury
CINI
PO 16742
Village: Daulatpur
P.O. Poilanvia Joka
24 Parganas
Calcutta 700 027
Ph. No. 033 4678192/4671206
Sanjay Kaul
Commissioner for Health and Family Welfare
IPP Building, 3rd Floor
Anand Rao Circle
Bangalore 560 009
Ph. No. 2874039
Fax. No. 2285591
Shanthi Baliga and Rekha
Family Planning Association of India
Bangalore Branch
“Srinivasa”, No. 26
D.N. Ramaiah Layout
Palace Guttahalli
Bangalore 560 020
Ph. No. 3360205
Fax. No. 331 1756
Shobha Maiya
Indo-Dutch Project Management. Society
No.35/1, New 95, Kanakapura Road,
Basavangudi,
Bangalore 560 004
Ph. No. 6521574
Fax. No. 6612891
Email, idpms@vsnl.com
5
SmitaBajpai
Coordinator Traditional Health Practices)
Centre for Health Education, Training
and Nutrition Awareness (CHETNA)
Lilavatiben Lalbhai’s Bungalow
Civil Camp Road
Sahahibag
Ahmedabad 380 004
Ph. No. 079 2866695/2868856
Res. Ph. No. 079 6740140
Fax. No. 079 2866513
Email, chetna@icenet.net
Sridhara
Community Health Cell (CHC)
No. 369, Srinivasa Nilaya
Jakkasandra
1st Block, Koramangala
Bangalore 560 034
Ph. No. 5531518
Email, sochara@vsnl.com
Sudarshan
Vivekananda Girijana Kalyana Kendra
B.R. Hills 571 441
Yellandur Taluk
Mysore District
Res. Ph. No. 08226-44025
Thelma Narayan
Community Helath Cell (CHC)
No. 369, Srinivasa Nilaya
Jakkasandra
1st Block, Koramangala
Bangalore 560 034
Ph. No. 5531518
Email. sochara@vsnl.com
Veena Shatrugna
National Institute for Nutrition
Taranaka
Hyderabad 500 017
Ph. No. 040 7018909
Vijay Thakur
A-15, M.H.A.D.A Complex
Vithal Mandir Road
Karvenagar
Pune 411 052
Email, vijay thakur@hotmail.com
6
Vimala Ramachandran
Educational Resource Unit
(Also Managing Trustee of HealthWatch Trust, Jaipur)
B 10 Vivekanand Marg
Jaipur 302001
Tele/fax No. 0141 360158
E-mail: rvimala@vsnl.com
V.R. Muraleedharan
Department of Humanities & Social Sciences
Indian Institute of Technology
Chennai 600 036
E-mail. vrm@acer.iitm.ernet.in
Hannah Piek
Shobha Raghuram
Reena Fernandes
Jamuna Ramakrishna
Susan Mathew
Julietta Venkatesh/Chandana Wali
Manjunath
Hivos
Flat No. 402, Eden Park
No. 20, Vittal Mallya Road
Bangalore 560 001
Ph. No. 2210514
Fax. No. 2270367
Email, hivos@hivos-india.org
Secretariat -
Hemalatha, Hivos and IIMB.
7
EQUITY AND HEALTH
By
Dr. N. H. Antia, FRCS, FACS (Hon.)
Director and Trustee
The Foundation for Research in Community Health
84-A, R.G. Thadani Marg, Worli Mumbai 400 018
Tel: 4934989/4932876 Fax: 4932876, C/o. 2662735
E-mail: frchbom@bom2.vsnl.net.in
i
EQUITY AND HEALTH
Human history is replete with examples of the struggle between the two contradictory traits
of human nature which differentiate us from all other species. At one extreme is greed
which demands instant gratification regardless of the long-term consequence to self or
others. And yet all prophets and wise men have preached the suppression of this
unfortunate trait which leads to unhappiness and which now poses a threat even to the long
term survival of our own and other species.
Health in its wider concept covers a gamut of social and economic aspects of human
activities such as nutrition, education and environment. Hence attempts at improving health
by focussing on an individual component such as curative medicine can only serve as a
temporary patchwork arrangement without appreciation of the many other factors and
above all of the socio-political forces which underlie both health as well as illness care. The
following examples will help to illustrate this.
In 1846 Rudolf Virchow,1 a German physician, questioned as to why the health of those
who worked in the mines of Silesia was worse than that of the citizens of Berlin. He also
stated that "medicine is a social science and that politics is the practice of medicine on a
larger scale".
The study of health in the UK from the feudal to the industrial, imperial and socialist stage
to the present neoliberal capitalist phase provides an interesting insight into the role of
changing socio-political influences on the health of the people. The onset of the industrial
revolution resulted in large-scale migration of the rural population to urban industries in
search of employment. This not only disrupted the human relationship, however tenuous,
between the feudal landlord and his tenants but also moved the workers from a relatively
healthier rural environment to the sordid unhealthy slums provided by single-minded profit
oriented industrialists. The workers had little choice. The appalling conditions in the early
phases of unregulated industrialization have been vividly described by Dickens. The
response was not improvement of the workplace as described by Owens and the home
environment by implementing the sanitary reforms of Chadwick, a city engineer, but its
rejection by the city fathers as a waste of public funds. The medical profession preferred
that the money be used to support larger public medical institutions called Infirmaries where
they could learn and practice curative medicine as a form of charity, while enjoying the rich
pickings from the care of the affluent members of their society. It was the fire of London
that burnt the unhealthy rat infested slums which resulted in the control of plague; not the
medical profession. The military aspect of the same industrial revolution also led to sudden
increase in the country's wealth as a result of colonization of countries like ours. Even a
minor trickle-down effect of this wealth resulted in improvement in the conditions of the
working class despite increased polarization of their society. Marx predicted the conflict
inherent in such a situation, where the working class which had risen above grinding
poverty would now organize to fight for social justice. While the predicted revolution did
not occur in the UK, the impact of even a modest alleviation of poverty and consequent
improvement of working and living conditions was evident in its dramatic effect on
2
tuberculosis. Macewan utilizing data provided by the registry of deaths per disease
maintained in Britain since 1860, showed the dramatic regression of this disease even
before identification of its causative organism by Koch in 1882 and tuberculosis virtually
disappeared in the UK before the discovery of vaccines or drugs; a clear demonstration of
the dramatic effect of even minor improvement in socio-economic changes on this as also
on other communicable diseases resulting from poverty.
The two internecine wars fought in the first half of this century by the European powers for
each other’s colonies also demonstrated two entirely different effects on health of these
countries. The economic depression of the 30s and the effect of devastation of the countries
of Western Europe like Holland in the early 40s resulted in a massive resurgence of
tuberculosis And yet no sooner than the economic conditions improved as a result of
political programmes like the Marshal Plan, tuberculosis vanished within a few years and
the hospitals and sanatoria had to be closed. This also demonstrates that the control of the
diseases of poverty also lies primarily in the field of political and social action and not that
of hospitals, doctors or of medical science, which are only supportive services.
And yet it was the result of these two wars that brought about a radical change in the health
of the people of Europe, as seen today. The use of the workers as cannon fodder by the
ruling classes of all warring nations also helped to raise their consciousness and demand for
their rights as equal citizens in so called democracies. This egalitarian upsurge is reflected
not only in the postwar unification of Europe but also in the dramatic overall improvement
of their economy which is also reflected in the health of its citizens. To them health is no
more an act of charity but a basic right of all citizen as for education, employment, food
security and welfare regardless of class, gender or economic status. The immediate post
war installation of the Labour Government in the UK resulted in the implementation of the
Beveridge report in both its letter and spirit even though this was one of the darkest
economic period of that country's history. The dramatic change that ensued in health which
resulted despite shortages of food, clothing, housing and basic necessities, once again
demonstrates how good health as well as good medical care can be achieved at remarkably
low cost when the necessary political will is manifest for an egalitarian society based on
sharing and caring.
And yet the Thatcher government, under the tutelage of the US, succeeded in backtracking
in many areas of the country's post-war socialist egalitarian form of development including
an attempt to privatize health. Yet it was the conservative British Medical Association
which had opposed the National Health Service (NHS) in 1947 who now stoutly supports
the people in refusing to dismantle the NHS. The Black Report of 1980 also revealed how
the health inequalities had widened during this period. This was also an important reason
for the reinstatement of the Labour Party. The renewed attempt of the present Labour
government under the tutelage of the US policy of globalization, liberalization and
privatization has also been strongly opposed by the people in the field of health, education
and welfare. A recent report shows how the infant mortality in the industrial cities like
Glasgow and Liverpool is twice as great as in the home counties. This also reveals the high
priority that the people at large assign to health and medical care as a social right which
once enjoyed they refuse to part with.
3
In contrast the US as the citadel of private enterprise has given almost unrestricted liberty
to the private sector operating for profit even in the field of health which is an area where
consumer resistance is at its lowest. Spending 14.5% of its GDP amounting to well over
one trillion dollars or $ 4409 per capita per annum, it provides a service which is far inferior
to that of the UK and other capitalist countries of Europe spending 9% of their GDP. Far
worse is that 45 million (15%) of its citizens have no insurance coverage for health and
medical care and have to depend on a service that resembles the Infirmaries of the UK
which existed two centuries ago.
The USSR, Cuba and China starting with a virtual non-existent health and medical care
service demonstrated how rapid strides could be made in both fields within a decade of
achieving independence. Like Nicaragua, they were able to achieve remarkable
improvement in education, health and welfare even while fighting on several fronts for their
country's very survival. Sri Lanka and Costa Rica as non-socialist states have also
demonstrated how similar results can be achieved when the national social conscience and
political will is high. Kerala a communist state of 30 million despite being a part of a larger
non-egalitarian democracy has shown remarkable results in education, population control
and health despite a low level of economic development. Spending about $ 25 per capita
per annum on health it has an IMR of 13 and a general health status which is not far behind
that of the US with an IMR of seven. These examples clearly demonstrate that the health of
the people of a country depends far more on its political organization rather than on the
expenditure on health and medical services that it incurs. Health is above all a function of
the social commitment and political will which also affects the efficient functioning of the
medical services. It also demonstrates that good basic health and medical care can be
provided to all citizens at remarkably low cost while there is no limit to expenditure on
curative medical care when it is converted into a commodity for sale in the private market
place.
We shall now try to examine the effect of changing socio-economic and political forces on
the health of the people of our own country from the Pre-British, British to the Post
Independence period in the last five decades.
Although no detailed information is available on health of our people in the pre-British era
we have documentation of the existence of an advanced civilization about 5000 years ago
in the Indus valley which had extended to what is presently northern Gujarat. The
excavations at Harappa and Mohenjodaro reveal remarkably well-organized habitations
including existence of baths and management of water and sanitation. In the following
period of Indian Renaissance which was about 2500 years ago, there emerged philosophers
like Mahavir and Buddha and rulers like Ashoka. This period was also associated with
advances in the science of health as well as of medicine and surgery. These have been
recorded in the samhitas of Sushrut and Charak. Though chiefly patronized by the elite in
the subsequent millennia this knowledge of health has become an integral part of the life
and practices of Indian society at large even to this day, often expressed in the form of
religious practices and rituals concerning food, hygiene, exercise and social behaviour.
Together with extensive knowledge of home and herbal remedies this has played an
4
important role in sustaining the mental as well as physical health and well-being of the vast
majority of our people even during the subsequent difficult periods and even to this day.
Not being dramatized and commercialized or enjoying political patronage like Allopathy,
we have failed to appreciate the role of these advanced indigenous systems in sustaining the
life and health of our people despite severe deprivation.
The writings of Bernier, Dubois and Adams reveal that the provinces of Bengal, Bihar and
Orissa were the richest in India and had the largest hoard of gold and silver in return for the
sale of produces like jute, muslin, indigo and opium. Bishop Reginald Heber also records
that at that time 'local women were as tall as European women'. Jaffar in 1765 records how
the economy of these provinces was ruined by a firemen of the Mogul Emperor which
permitted the East India Company the duty free import and export of goods. The Company
freely issued permits known as 'dastaks' which ruined the age old business industries which
resulted within 15 years in the 'dastak famine' of 1769-70 which according to Hunter
resulted in the death of 1/3 of the population of this region.
This systematic loot of the wealth of our country has been well documented by Dadabhoy
Naoroji and others. Except for a few favoured elite and the sepoys of their army, the impact
on health of two centuries of foreign domination has been demonstrated by the life
expectancy of 20 years as recorded in the 1911 census. As a result of the pressure of the
Congress movement and health being transferred to local state ministries there was certain
improvement as reflected in the census of 1941 when life expectancy had risen to 32 years.
A further marked improvement in life expectancy to 46 years was achieved by 1961 as a
result of Independence. This has now reached 60 in the 1991 census.
The dramatic improvement in the first two decades following Independence was
demonstrated by the eradication of smallpox, almost elimination of malaria from 100 million
to less than 100,000 cases and control of cholera and plague; the four major scourges of the
pre-independence period. What is even more remarkable was that this was achieved with
the then available simple medical knowledge and technology, very limited financial
resources, and only a handful of dedicated public health officers. This was possible only
because of sustained support by a strong political will to ensure that the benefits of
Independence should reach all those who had struggled for achieving Independence. There
was also an equally enthusiastic response by the people themselves who had participated in
the struggle.
And yet the improvement in the following two decades is nowhere commensurate with
what was achieved by China during the same period using the decentralized 'barefoot'
approach. China's life expectancy in 1991 had reached 70 years as compared to 60 of our
own. The deterioration during this period was despite the availability of vastly improved
medical knowledge and technology as also of medical manpower and infrastructure.
Unfortunately unlike China after the first flush of independence the Indian scene was
increasingly monopolized by an increasingly self centered political leadership supported by
an equally over-centralized, over bureaucratized, over-westernized and over-urbanized
public sector which alienated rather than encouraged the involvement of the people in their
own health and medical care. These decades also resulted in massive proliferation of the
5
profit-oriented private health sector interested in lucrative curative medicine but not in
preventive or promotive aspects of health. This was in conformity with an increasingly
polarized society controlled by those whose single-minded interest was on creating a
lucrative milieu for a small elite segment of our society living in urban enclaves and whose
desire in 'health' was for the 'latest' expensive curative medicine as practiced by their US
mentors rather than even the more socialist UK model. This has been reflected in all aspects
of our country's development during this period. This was despite India adopting the
democratic mode of development but where the majority of the people were marginalized
and deprived of education and information with the consequence that they had little say,
leave aside influence, in decisions affecting their own welfare.
The statistics that have been provided by the government are almost invariably of an
aggregate nature. In a highly polarized society this conceals more than what it reveals. In
1997, Kerala2 had an IMR of 13 while in the UP it was 85 while the All India figure was
71. Such figures generated in backward states under political and bureaucratic pressures are
even more suspect. Aggregate urban statistics inform us that urban health is twice as good
as that of the rural areas. And yet it fails to reveal that the statistics of half of the urban
population comprising of the upper classes has a health status equivalent to that of the
affluent West, while that of the slum dwellers who comprise the other half of the urban
population is as bad or even worse than that of their rural counterparts. The remarkable
achievements in education and health in Kerala is more the result of female education than
of medical services; also that these statistics are reflected uniformly in all districts of this
state. In contrast the infant mortality of the poorest families of the poorest villages of the
poorest district in the backward BIMARU states is probably in the region of 500 where
every second child that is bom dies before reaching the age of one year. No wonder the
Family Planning programme in Kerala has to emphasize that non-terminal methods of
contraception should be practiced till their two children reach the age of 5 years. On the
other hand the poor in the BIMARU states know that a hostile political and bureaucratic
system considers them only as a population threat which dilutes the gains of development,
without providing even basic subsistence and care of health during illness and old age. It is
conveniently forgotten that under such conditions these families need eight children for
mere survival leave aside deserving of some love and affection in an increasing hostile
world.
This marked change in the approach and direction to health and medical care following the
first two decades following Independence has been in keeping with the overall change in
the political will among the subsequent generations of our leadership often based on
dynastic considerations. The change was from an egalitarian to a more selfish approach
designed by and for the benefit of a small 'creamy' layer which has ceased the reins of
power. This has been at the expense of the masses who had fought for the country's
Independence under the dedicated leadership of those like Gandhi, Nehru and Patel. The
shift in health was from an egalitarian Health for All to Wealth for a Few. This change in
national development to a capitalist form of governance under the guise of representative
democracy, has also adversely influenced its health policy, which in turn has been influenced
in no small measure by the western powers led by the US.
6
This was responsible in transforming the integrated health and basic medical care approach
of the Bhore Committee designed3 for a predominantly rural nation with limited capital but
unlimited human resources, to one based on the latest expensive high technology for the
urban rich. This was the result of willing cultural and economic cooption of the dominant
elite by the West which had increasingly become their role model of success.
Following the collapse of the USSR in the early 90s, including that of its remarkable health
and medical facilities, the same strategy has been utilized in an even more aggressive form
for neocolonization of the newly independent' need based' countries by utilizing the same
economic and cultural weapon devised as early as 1948 at Bretton Woods for redomination
of the world. Under the guise of globalization, liberalization and privatization these agrarian
Asian economies were artificially overheated into a state of Western style industrialization
by provision of extensive loans. Using the rich local natural resources and cheap labour by
corrupting the local leadership this not only polarized their societies and created social
disruption but reduced them to a state where their trade and even the mode of governance
could then be dictated by the US and other Western multinationals in search of quick profit,
regardless of the pauperization of the majority of their population. A replay of the previous
five centuries of global exploitation through a form of trade' dictated by the European
powers but now using a subtler technique than the crude gunboat diplomacy of the past.
Beginning with industry this has now extended to the service sector. In a globalized market
place there is no better field for exploitation than health, since it is an area where consumer
resistance is at its lowest. The socially, culturally and economically overawed and corrupted
elite leadership, who control the levers of power, have proved easy prey to the systematic
assault mounted by the pharmaceutical and medical instrumentation industry which has
distorted the values and ethics and even corrupted the age old medical profession. This is a
part of the undermining of the values, morals, ethics and practices of older civilizations by
aggressive promotion of the baubles of mindless materialism generated by Western science
and technology with Mamon as the reigning deity. Advanced systems of health and medical
care like Ayurveda and Yoga which have sustained the health of our people over the ages
have been systematically denigrated as being unscientific' unless validated by Western
scientific paradigms or converted into marketable commodities. While ISM and
Homeopathy are provided lip-sympathy by our own government, they receive less than 4%
of the national health budget.4 The production marketing and consumption of drugs5 and
pharmaceutical starting at Rs. 10 crores at Independence has now reached a mind boggling
Rs.25,000 crores which now comprises over 50% of the overall expenditure of our country
on health' which at 3.5% of the GDP is equivalent to Rs.54,374 crores. More than three
quarters of this excessive production is consumed by the private health sector which ranges
from 5-star hospitals and nursing homes to doctors roving the villages on motorcycles,
providing unnecessary expensive and even dangerous injections and medicine to those who
pay under duress of pain, suffering and death. This is the result of undermining of the public
health sector by political and bureaucratic interference and a further 'cut' of 20% of its
budget imposed by the IMF, the sister concern of the World Bank, under the guise of the
Structural Adjustment Programme. Combined with the implementation of Fifth Pay
Commission's recommendation,, over 90% of the public health sector budget is utilized in
7
paying the salaries of staff. After6 imposing such sanctions further loans are freely offered
by international usurers, and equally willingly accepted by our government, for facetious
programmes like DOTS for tuberculosis. Impregnated bed-nets for control of malaria and
for building and equipping PHC when the failure of the existing ones is the result of
bureaucratic interference, inefficiency and lack of motivation and accountability to the
people. The importing of highly expensive diagnostic, medical and surgical equipment,
most of which is inappropriate for our country and its economy is in a stage of
obsolescence. Such 'health' care promoted and welcomed by our elite now presents another
lucrative avenue for multinational business and industry. Even the poorest are not spared
since increasing poverty and its associated illnesses are now diverting alftiost 20% of their
meager household expenditure from food to such inappropriate form of medical care. We
are now told that the answer lies in handing over the ailing public assets like hospitals and
PHC to the 'more efficient' private sector, together with the recurring expenditure. This
privatization and appropriation of public assets by a sector well-known for its predatory
instincts and practices is another bonanza for those who seek to enjoy the benefits offered
by the globalized market. The privatization of health insurance now offers another avenue
for such trade in human suffering. Surely, those who dictate such policies from Washington
know the evils of converting people’s health into a business and industry from the
experience in their own country.
The effect of this latest assault by a combine of international and national governments,
organizations and agencies is demonstrated by the rapid deterioration of the health of our
people during the present decade and the dramatic resurgence of diseases which had been
controlled such as water-borne diseases like cholera and typhoid, vector borne diseases like
malaria, filariasis, kalaazar, dengue, encephalitis and plaque and diseases of malnutrition
such as tuberculosis and ARI. This has occurred despite vastly increased financial inputs
which evidently are of the wrong type and resulting in demand for further loans which
increase international indebtedness and imposing of further 'conditionalities' by IMF; an
unending vicious cycle. In such a form of health and medical care the rich are dangerously
over-investigated and over-medicated, the middle class pauperized when they fall ill, and
health' services are diverting scarce resources of the poor from nutrition to medicines,
doctors and drugs. Malpractice has assumed proportions unbelievable only a few decades
ago. The urban poor living in slums suffer from a double burden not only of such diseases
but in addition those of pollution of air, water and food. Even the rural population suffers
from poisoning as a result of excessive promotion of pesticides and fertilizers.
Instead of addressing the specific health problems of our country and its people at large
following Independence we are being dictated by international organizations and their
itinerant experts from Geneva and Washington; some with good intentions though
distanced from the reality of'need-based' countries, while others have different motives and
agendas of their own. AIDS provides a good example of the endless stream of vertical
programmes imposed on our Ministry of Health and Family Welfare without consideration
of local social, economic and cultural realities, which are far better understood by our own
experts who are sidelined if their opinion does not support the advises of the 'aid' providing
donors. Their advice based on limited Western experiences is in start contrast to the
integrated approach necessary to solve such problems. Over 400,000 deaths have occurred
annually in India for the past 50 years. Yet it has remained to AIDS with a few thousand
8
annual deaths, a disease coming from the West, to draw attention to the far greater national
problems of tuberculosis which is also essentially a disease of poverty. Even concerning
AIDS the creation of mass hysteria by the use of modem mass media can only create more
fear than awareness. Like leprosy another stigmatizing disease of which India has ample
experience, it has been shown how such propaganda can drive such diseases underground
in their early stages. The almost hysterical propaganda of AIDS promoted by the West with
generous loans has resulted in increasing the stigma to tuberculosis with which this disease
is now associated in the public mind. This can hence even hamper the control of
tuberculosis. Substantial loans are now provided for such ill-conceived programmes which
can only sink the country into further international debt without any significant impact on
our people's health and can only result in further increase the diseases of malnutrition and
poverty.
The control of the diseases of poverty does not lie in the present spate of vaccines that are
being devised in Western laboratories which when available for diseases like hepatitis, fail to
reach those most in need because of cost combined with a grossly ineffective mode of its
delivery. The most desirable vaccine for controlling the diseases of poverty is a vaccine
against poverty itself which can be achieved only by a concerted international political will
for an egalitarian form of world order of which health would be a major beneficiary.
Though poverty has been created by the global policies of the West, we are informed by
them that there is no means for curtailing this. What is worse is that the diseases created by
such poverty are also converted into another lucrative business and industry by their
multinationals.
The role of politics in our country's development and its effect on health was clearly
visualized by Gandhiji both before and after Independence. While the illiterate masses stood
by him in the struggle against British rule, he foresaw that despite the Trusteeship concept,
those educated elite who had sat on the fence during the struggle and who would gain the
reins of leadership and power in the next generation could not be implicating trusted to
look after the interest of the masses in Independent India. His remarkable vision based on
an uncanny understanding of human nature made him ensure that the ultimate power be
vested in the hands of the people themselves in the form of the vote by incorporating
Universal Adult Franchise in the constitution; this despite the apprehension and strong
objection of the educated elite. After 50 years of a tortuous course of events during
operation of the Representative form of democracy, the people of this country (as opposed
to most other countries who gained Independence during the same period and opted for
democracy) have been able to exert the power of their vote which has enabled them to
achieve Panchayati Raj as perceived by Gandhiji. This is now a constitutional right, through
the enactment of the 73 rd and 74th Constitutional Amendments in 1993. The health of our
people will ultimately depend on the outcome of the ongoing struggle which may be
justifiably called the Third Struggle for Independence' whereby the people will regain their
power and rights which have been appropriated by their elected representative under the
guise of Representative Democracy. This can be achieved only through Panchayati Raj
which is the only true form of democracy viz. Participatory Democracy. The Right to
Information and even Right to Recall deviant elected leaders is being sought by the people
who are now increasingly aware of the importance of the power of their vote for regaining
9
their economic and social independence. They are no longer willing to accept development
in the existing form of urban industrialization imitating the Western model which produces
consumer goods and services for the elite when there is ample evidence that rural small
scale agro-industrialization is far more humane as well as cost-effective and whose benefits
accrue to the people at large and not to a select few. A form of development which is also
compatible with Education and Health for All.
Despite adopting a Westernized model, the Bhore Committee's report was the original
concept of equity in health and medical care for all citizens and was adopted by the founder
fathers as the model for our country's health policy following independence. Though India
was a signatory to the WHO Alma-Ata Declaration of Health for All in 1978, the mere
signing of the declaration had little if any impact on our health policy or its implementation.
This was because by then the political will of our leadership had already changed to a more
selfish objective of the succeeding generations of elected politicians. This noble declaration
of Health for All was used by India, like most other signatories, as a convenient rhetoric to
dupe their people while health was converted into a marketable commodity to serve a select
few of their citizens. Even WHO itself soon converted this holistic and integrated concept
of Health for All into a narrow Specific Primary Care approach which has further destroyed
the integrated , model of the Bhore Committee.
It was the independent ICSSR/ICMR report Health for All: An Alternative Strategy in
1981 which after reviewing health in its larger socio-political-economic dimension
provided an alternative highly cost-effective model for health in which the people have to
play the dominant role. This independent report clearly stated that this could not be
achieved unless , the people, and not mere elected representatives and bureaucracy
controlled this model. All the non medical components of health and even 80% of all
medical components viz. preventive, promotive as well as curative medical care can be best
undertaken by the people themselves at the village level with their own local women
provided with highly specific and practical training in the problems affecting the health of
their community using all methods and systems of health and medical care. Also that over
95% of all problems including specialized medical and surgical care could be tackled within
the 100,000 population block/taluka level. This report also clearly stated that this could be
achieved only under Panchayati Raj where the people would have both financial and
administrative control over all functionaries and activities at their level. Only this could
provide the dominant social and human component of health and medical care which is so
lacking in the existing public and private sectors. Above all this would ensure accountability
to the people without need for 'targets' and transfers. This would also overcome the
problems of unionization which plague the existing bureaucratic system and ensure that
salaries would be in keeping with local rates. A many faceted improvement on the existing
system. Such a decentralized people controlled system would ensure adequate manpower,
infrastructural and medicinal requirements as would be determined by the needs of the local
people than by a distant national and international bureaucracy with their own perceptions
and interests. Like in the UK, such an effective People's Health System would also be the
most appropriate means for controlling the otherwise unaccountable private sector.
The 73 rd and 74th Constitutional Amendments empower people to undertake the 29
io
subjects affecting almost all aspects of their life, including health, at each level of the
Panchayat system. The struggle for transfer of power and with it the resources is now an
ongoing process which can be delayed but not reversed in what is now the true form of
democracy of a face to face Participatory nature and not of a distant Representative type
which has failed to deliver the goods. This is the democracy conceived by the founder
fathers of our nation, an age-old practice suited to the 700,000 villages of our country.
11
REFERENCES
1.
Virchow Rudolf. Collected essays on Public Health and Epidemiology, Vol.l&2,
Edited by L.J.Rather 1985.
2.
UNDP. Diversity and Disparities in Human Development: Key Challenges for
India, UNDP, New Delhi, 1999.
3.
Government of India. Report of the Health Survey and Development
Committee. Government of India Publication, 1946.
4.
Government of India, Ministry of Finance. Economic Survey 1998-1999. Economic
Division, Ministry of finance, Government of India, 1999.
5.
Phadke Anant. Drug Supply and Use: Towards a Rational Policy in India. Sage
Publications, New Delhi, 1998.
6.
Rao Sujatha. Financing of Primary Health Care in Andhra Pradesh: A Policy
Perspective. Centre for Social Services, ASCI, Hyderabad, 1997.
7.
1CSSR/ICMR Health for All: An alternative Strategy. Indian Institute of
Education, Pune, 1981.
12
July 29 1997
PROTECTING CONSUMER’S HEALTH IN DEVELOPING COUNTRIES
DEBABAR BANERJI
Professor Emeritus,
Jawaharlal Nehru University
and
Nucleus for Health Policies and Programmes,
B-43 Panchsheel Enclave, New Delhi
Tel.6496851
1
The terms, 'developing1 and 'developed' countries will be used in a broad, generic
sense. It is not necessary here to enter into a semantic debate concerning definitions. It
is also recognized that there are considerable diversities among the countries put
under these two groups. The emphasis here will be that, taken as groups, these are
'poles apart' in more sense than one. Their relationships are based on unequal terms.
For reasons that need not be gone into here, developed countries generated conditions
which created the phenomenon of European Renaissance. Development of science,
technology, industry and commerce gave them a head start over the developing
countries. This enabled them to acquire strong political and economic control over the
other group. This gap has been widening all through the centuries. Developing
countries are made to lose their autonomy in decision making on issues that vitally
concern them. They are left behind to follow the mirage of 'catching up’ with the
developed ones.
Western medicine has developed under such a setting. It registered spectacular
breakthroughs, particularly during the past century and a quarter. From a scientific
angle, it has reached dizzy heights, as manifested, for example, by advances in
diagnostics, special surgical procedures and a wide spectrum of therapeutic practices.
Over and above, new areas such as genetic engineering, biotechnology and in vitro
culture of tissues of organisms, which includes humans.
As observed by the great German medical thinker in the mid-nineteenth century,
Rudolf Virchow, 'medicine is a social science’; it is greatly influenced by social
forces. Three major social forces which has influenced medicine will be very briefly
referred to in the following paragraphs.
The issue of access of medical and public health services to the people had come up
since the time of Bismark, when he developed 'socialized medicine' in Germany.
People in the present developed countries had to struggle hard to obtain universal
access at least to fundamental health services/insurance. Today, in most of the
developed countries the state accounts for above eighty per cent of the total cost of
health/insurance services. Even in the US, it is over fifty per cent. In a startling
contrast, in a massive developing country like India, the percentage is less than
twenty-five. To further compound the situation, now, under the Structural Adjustment
Programme (SAP) pressure is being exerted on the country to further 'downsize' state
intervention in the field of health.
There has been considerable unease over the way Western medicine is being practiced
even in the developed countries. Ivan Illich is among those who made a
comprehensive, well-documented critique this vital area. He starts his famous book,
MEDICAL NEMESIS, by asserting that medicine has become a threat to the health
of the people'. He substantiates his arguments by drawing attention to various kinds of
iatrogenic diseases - diseases caused by practitioners of medicine. Medicalisation of
lives of people, mystification of medicine, professionalisation and centralization,
dependence creation and actively promoting addiction to medicine, are some of the
2
terms he has employed for making a devastating denunciation of practice of Western
medicine.
So powerful have been the economic interests behind the 'sale' of Western medicine
to the consumers that the overwhelming evidence adduced against these aspects of the
practice were simply ignored or 'forgotten' and they have succeeded in generating an
exponential growth of the highly faulted medical system all through the years. This
has substantially added to the GDPs of the developed countries. Medicine has now
become a commodity. Big corporate organisations have come into being to sell
medical services to customers are 'suitably motivated' by subjecting them to relentless
bombardment with well-designed media onslaughts. For instance, an entirely new and
booming 'fitness' industry has now come into being to sell 'fitness' to such
intellectually sanitized people, who are conditioned to rush to buy designer made
paraphernalia of various kinds.
After ensuring that markets are thrown open to 'free trade' by imposing the SAP on
developing countries, the developed countries have expanded their market by
including the much vaunted burgeoning middle class in the developing countries in its
brainwashing agenda. To the 'forgotten' people of the developing countries, those
'who live on the other side of the moon', these business ventures in medicine conform
to what Illich had observed long ago - a menace to their health. Perhaps unwittingly,
physicians have often become sales agents of this massive 'medical industrial
complex'. That President Clinton could not push through even the very highly diluted
health care programme for the people of the US, despite most solemn promises made
in his campaign to get the second term, attests to awesome power of the business
interests. Those who live on the other side of the moon in the US were bluntly told
that there is 'no free lunch'. This conforms to famous saying of the US president just
before the Great Depression: 'The business of the US government is business'.
This was the structure and content of Western medicine which the developing
countries encountered when it was inducted into these countries by some of the
developed countries in the wake of colonial/imperialist conquest. This encounter has
to be considered here both in terms of time and space, against the overall social,
economic and political dynamics. When Western medicine was imposed on the
different developing countries, the people there had their own, indigenously
developed mechanisms for coping with their health problems. The motive force
behind the induction of Western medicine in these countries was to provide protection
to the ruling class.
In the countries which were colonized by the developed countries, it was made
accessible to the military, the colonial administrators and the traders; it was also made
accessible to the wafer-thin uppermost level of the native gentry, which collaborated
with the exploiters. Thus, right from the initial phase. Western medicine was used to
strengthen the exploiting classes. The increasing impoverishment of the exploited as a
consequence of colonialists joining the local gentry to extract some extra revenue
created conditions for increasing the already heavy load of diseases and deaths among
them. At the same time, with the native elites developing a fascination for Western
medicine, the quality of the indigenous practices that were developed to cope with
3
their health problems over centuries suffered because of lack of nurturing of these
practices. The vast masses of the people, the 'forgotten' people, thus suffered
additional disadvantages when Western medicine was introduced in these countries.
However, here too there was a dialectical response from the people. Conditions
generated by the anti-colonial and anti-imperialist struggles impelled the leaders' of
the movements to think of ways to meet the health services needs of the vast masses.
Significantly, because of fundamentally different socio-cultural, economic, political,
epidemiological and technological conditions, the response too had to be
fundamentally different, thus laying the foundations of what is now being termed as
New Public Health. It had been a long, grinding struggle for the masses. The idea of a
Barefoot Doctor' took the final form in the post-revolutionary China, while the
leaders were groping for alternatives. During the anti-colonial struggle in India
evolved the idea of the Primary Health Centre to provide low cost, efficacious
comprehensive health services to the unserved and the undeserved populations and
that of 'entrusting people's health in people's hands' through Community Health
Workers elected by the communities. Scholars from other countries also contributed
to the growth and development of this new, people-oriented health services which are
tuned to the specific conditions prevailing there; 'health by the people'.
Under the leadership of Halfdan Mahler, WHO not only encouraged this trend, but it
actively acted as a catalyst to give the movement considerable momentum, which
culminated in the World Health Assembly (WHA) adopting the famous resolution on
Heath For All by adopting the approach of Primary Health Care by the year 2000 AD
(HFA2000/PHC) and getting all countries of the world specifically endorse the new
philosophy in the Conference on PHC at Alma-Ata in 1978.
The Alma-Ata Declaration marked a watershed in the history of public health practice
in the world. Health was declared as a fundamental human right for all the people of
the world. People, rather than technologv and industry were considered to be prime
movers; community self-reliance or community involvement in every phase of health
service development was the keyword. Social control over the health services;
intersectoral action in health; coverage of the entire population with integrated health
services; use of technology that is appropriate for the people, including use of
traditional systems of medicine; use of only a very limited number of essential drugs
in generic names, were some of the highlights of the Declaration. Halfdan Mahler also
took the initiative in getting the approval of the WHA to have a WHO Programme on
Essential Drugs; the WHA also approved for enforcement a Code for marketing of
baby foods in the poor countries of the world.
The response from the rich countries to the poor countries daring to declare selfreliance in health was swift and sharp, as it affected their economic and political
interests. They 'invented' the very untenable concept of Selective Primary Health
Care. They used their financial clout to mobilise international organisations like the
Word Bank, WHO and UNICEF to let loose a virtual barrage of international
initiatives’ on the poorer countries, which almost swept away the tentative steps that
were taken by some of the poorer countries in implementing HFA 2000/PHC. These
4
extreme poverty; malaria still strikes up to 500 million people a year, killing at least
two million; acute respiratory infections kill almost four million people every year;
tuberculosis kills three million annually; Diarrhoeal disease still kill nearly three
million people every year; AIDS has infected up to 24 million people, out of whom
four million have already died.
An account of the hundreds of millions of premature deaths and easily preventable
diseases faced by the 'consumers' of health of those who accounted for almost the
entire populations of many of the developing countries is a part of the account of long
running confrontation between the 'haves' and the have nets' on grossly unequal
terms. Political leaderships of the developed countries provided the major striking
force for the oppression of the have-nots; the haves among the natives actively
collaborated with them in carrying out this oppression. Inevitably, despite their
tremendous disadvantage, as they have little to lose, the haves' have mounted a
sustained struggle against injustice and exploitation. The consumer movement for
health in the developing countries will take the side of the wronged people. Their
demands are enshrined in the Alma-Ata Declaration - this includes struggle for a
rational drug policy, access to people oriented health services and a more humane and
broad based, empowering population policy. This part of the struggle for human rights
of the have-nots. History ordains that this struggle will continue.
POVERTY, HEALTH SERVICES AND DEVELOPMENT
An overwhelming proportion of the poor people of the world live in developing
countries. About a third ofthem are abjectly poor, in the sense that they are unable to
get even two square meals all round the year. Another third or more, though somehow
manage to have the two square meals, nevertheless, live most degrading lives. These
people have thatched huts, shanties or overcrowded dilapidated buildings for their
living. Very few of them have sanitary latrines or easy access to protected water. The
overall environmental sanitation is exceedingly poor, with virtually no arrangements
for disposal of human, animal and kitchen waste, and drainage of wastewater. Various
kinds of insects and pests thrive in the ecological conditions created by these
deplorable levels of human existence. Earning of the meager resources for keeping
alive entail hard, backbreaking work, often under hazardous conditions. Amelioration
of these conditions need social and political action to usher in a more just social and
economic order.
The very well-off section of the populations in these countries, constituting the upper
5 percent or less of the populations, have acquired the power to dominate the social,
political and economic lives of the rest of the population. From time immemorial, the
poor have undertaken struggle to wrest their rights from the dominant rich.
These also create conditions for high levels of incidence and prevalence of various
kinds of acute and diseases which sap the lives of the people; the suffering caused by
the diseases further disempower them, thus leading to the perpetuation of the unjust
social and economic relations. It is in this context that provision of easy access to
health services acquire a political significance: (a) it empowers people by
7
substantially alleviating the huge load of the suffering caused by diseases; (b) an
additional source of empowerment is the consciousness that is generated among the
hitherto neglected people about their right to have services from public institutions;
and, (c) perhaps more importantly, availability of access to health services can act as
an entry point for the people to demand equity in such other fields as education,
employment, land rights, access to protected water, housing, environmental sanitation,
social and economic justice, and so on; health services have thus the potential of
serving as a major lever for all-round development of the hitherto neglected and
exploited segments of people of the developing countries.
The adoption of the Alma Ata Declaration by all the countries of the in 1978 world
was a landmark in the oppressed people's struggle to wrest their rights from their
oppressors. Subsequent events have shown that the oppressors have managed to
thwart this important movement for self-reliance in health.
f
8
<* I *<*99 The Society for International Development. SAGE Publications
lUmdon.Thousand Oaks. CA and New Delhi). 1011-6 J70 <199912'42:4: 54-5S: 010922
o
Negotiating New Health Systems
The State and Civil Society: Meeting
health needs, reaching equity
SHOBHA RAGHURAM
AND MANASHI RAY1
ABSTRACT Shobha Raghuram and Manashi Ray examine the health
standards for the poor in India within the broader context of human
development concerns during the last decade, with special emphasis
on the role of the state and its commitment towards achieving
'health for all'. They discuss the response of civil society in issues of
public health and in monitoring the accountability of the state,
underscoring the need for reforms in the state services.
Globalization and health
While globalization has been thought of as positively contributing to setting
standards globally, the divides in quality of life have become even more stark and
worrisome. Health has been a sector of silent neglect in many countries receiv
ing scant attention when it comes to financing all related public health needs.
The severe local and global imbalances in the enjoyment of health call for radical
measures that will bring greater equilibrium in people's access to health. The
minimizing of the role of state and the increasing reliance on market mechan
isms to address welfare needs during the reform period has not solved the issue
of millions of people globally living with unmet needs. The discussion on globaliz
ation. equity and health should not be laboured under the same rubric of growth
and liberalization. The state may indeed have performed too little in the areas of
basic needs. What is required is the maximization of the state in providing suf
ficient conditions for basic needs provisions. Sen and Dreze (1996). when writing
about intrinsic value and human capabilities, drew the attention of policy
makers to the excessive concentration on issues of liberalization and market-led
changes which have detracted from the fact that the social sector areas have suf
fered from too little role of government and not the other way around. It is clear
that the grueling data of existing poverty in the country has completely influ
enced the profile of ill health. The political economy of health will in the coming
years be a critical area of work as poverty, health and development closely inter
connect. thus influencing the overall arena of social equality.
Raghuram and Ray: The State and Civil Society
Role of state and equity: the
India case
The last 51 years of development history for India
have shown the limits to polin’ and the greatest
need for consolidated social and political action
taking place at the most micro-levels and at the
same time the need to evaluate national govern
ments which, in the larger sphere of state role,
advocate policies which undermine human
development. Historically, after independence, the
government, in response to the large numbers of
poor in unequal health circumstances, made many
committed pronouncements pertaining to improv
ing the lot of the vulnerable in the official planning
processes. The 1978 ‘Health for All’ Declaration
received a full-fledged commitment from the Indian
government and this was important in order to
propose a broad and consistent philosophy towards
a strategy secured in the primary health care PHC
approach.
Today, an examination of the status of health
indicates that there is surprising unevenness across
borders. In addition to the rural/urban divide, the
caste, class and gender disparities in health persist,
giving rise to a situation in which different pockets
of population within the same country portray dif
fering health status. The availability of access to
social infrastructure is uneven between social
groups, economic classes and geographical regions.
The scheduled classes and tribes, in particular, and
the poor, in general, are being adversely affected.
Health problems associated with underdevelop
ment (among the poor and the disadvantaged) and
the extent of transitions which are creating a ‘polar
ization’ of health between different groups have
been the grounds for public action. For policy
makers designing appropriate policy but also
measuring the benefits of competing health invest
ments on different groups of population is critical.
Social development and health
during the reform years
There has been a great deal of discussion regarding
the negative effects of the reform measures on the
social sectors, especially in countries like India with
high figures of poverty and its attendant forms of
destitution.
The SAP initiative adjustment programmes in
mid-1991 led to expenditure compression in Union
Government finances in the first 2 years. The situ
ation improved in subsequent years with an
increase in the allocation to rural development,
education and health. The cuts were severe in the
first two years of the reforms, followed by some
restoration in the next four years. The greatest
casualty was health care. As opposed to this, the
almost exclusively centrally funded family plan
ning programme fared much better even in the
worst resource crunch years.
The ideological underpinnings associated with
the reforms package legitimizes the state’s with
drawal from infrastructural areas, including
infrastructure in social sector. The projected
inability of the state to finance health care has
been further used as a lever for the privatization of
health care.
During the decade of the 1990s. with the inter
national and bilateral funding of some health pro
grammes there was a gross distortion of priorities
in disease control and health development. The
1992 budget had seen one quarter of the planned
Central Health Budget being allocated for
HIV/AIDS, while the budget for malaria control
had been decreased by 43 percent. Major diseases
like tuberculosis and diarrhoea which cause high
morbidity and mortality were neglected. It is
important to note that the greatest killers in the
post-reform period continue to be cholera. TB.
malaria, and kala azar (Voluntary Health Associ
ation in India. 1997). In the case of malaria, the
incidence figures have been at roughly 2 million
cases every year, affecting mostly tribal popu
lations. On the whole, after the initiation of econ
omic reforms in the 1990s. the sustainability,
health priorities and the future of public health
programmes have been greatly influenced by exter
nal assistance and have not been pro-poor or propeople. It is difficult to assess the extent to which the
reforms have had an adverse affect on health in the
1990s. However, it can be postulated that because
of considerable decline in the public expenditure in
the first few years of the reforms, there might have
been adverse impact on the overall human develop
ment indicators.
55
Development 42(4): Negotiating New Health Systems
56
Health security and the poor: a
matter of responsibility?
as between more vulnerable, poor areas and the
privileged urban centres.
The state as the primary and critical actor in ensur
ing equity urgently requires the consideration of
an overall plan which can strategically strengthen
the sector of health in the overall plans of develop
ment and poverty eradication. The financing of
poverty alleviation programmes as well as social
sector services requires a comprehensive effort
both on the field and in the budget exercises. Health
policy will increasingly need to be designed keeping
in mind both national and local agendas.
Market considerations have often flawed an
overall social justice agenda and the wider canvas
of human security is the basis for the serious
management of public health. The primary objec
tive of the National Health Policy (NHP) which was
adopted in 1983 w*as to attain the creation of an
infrastructure for primary health care. Other major
priority areas were: close coordination of health
related services and activities like drinking w'ater
supply, sanitation and nutrition: the active involve
ment and participation of voluntary organizations
and the provision of essential drugs and vaccines.
The 1980s witnessed a massive infrastructure
expansion and the creation of programmes for pro
viding family health care facilities. However, in
spite of the vast expansion in infrastructure it failed
to work due to poor facilities, inadequate supplies,
insufficient effective person hours, and the lack of
proper monitoring and evaluating mechanisms. A
bureaucratic approach, insensitive to recognizing
and involving people’s organization in the
implementation of the family welfare programmes
in the country forced the continuation of the use of
private health services.
The other issue has been the effectiveness of
expenditure incurred in terms of human develop
ment outcomes, and the relative importance of
economic growrth and public provisioning in capa
bility enhancement of states (Chelliah and Surdarshan, 1999). Thus, there are severe imbalances in
India between public and private health care,
within public health care between preventive and
curative services, between primary, secondary and
tertiary health care services, and between salary
expenses and other recurrent expenditures, as well
Regional diversities and
contrasts in health status
Progress over the decades has been uneven and
remains confined to more advanced states and.
even within them, to selected regions only. The
health status of a large part of the Hindi speaking
areas of north India, as well as the states of Orissa
and Assam, remains adamantly vulnerable.
Further, the more remote, sparsely populated
and resource-poor an area is. the greater are the
chances of its neglect, in terms of the availability
and effectiveness of health services. The floodprone areas of Assam and Bihar and slates lying
along the Bay of Bengal suffer from the endemic
presence of vector-borne diseases and frequent
damage to infrastructure. The people in these areas
- be they tribals, scheduled castes, displaced or
migrant populations in search of work - remain
ignored and are compelled to accept a lower quality
of life. Preventive and public health care measures
and primary health care services do not reach them
adequately. Therefore, the political economy
impinging on health policy development and its
implementation has given rise to the conspicuous
disparity in the health outcomes. As a result, there
have been neglected areas, forgotten populations
and overlooked issues. Each of these distortions is
damaging enough, but when all three exist the situ
ation is fairly acute.
Reform of the State and the role
of civil society: a case for
cooperative public action
Issues taken up by grassroots voluntary organiz
ations include food security, political participation,
health, urban poverty, migration, and land alien
ation. Governments have many mechanisms at
their.disposal for replicating good models that
might emerge from the extensive micro-level
experience that non-governmental organizations
have of given communities, which help them to
perceive genuine interests and to build organic
links on the field. In the area of health, which
pK06703
M'O'’
X-
IA
■■■■
J
Raghuram and Ray: The State and Civil Society
involves a spectrum of collaborative efforts, politi
cally voluntary organizations need their autonomy
from governments, as they instrumentalize differ
ent social and political interests. The mutual
accountability that is being demanded of govern
ment-voluntary organizations relations requires
institutional integrity (e.g. transparency), particu
larly to the communities involved. How they may
be asked to integrate their efforts with those of the
state, which is itself in the process of integration
with global interests on terms clearly not set by the
people themselves, is a thorny and painful issue.
Social justice, accountability, high standards of
morality and equality are issues that cannot be
realized historically without majority consensus.
For voluntary organizations or social movements
the challenge lies in enabling basic needs and
democracy mainstream concerns, cutting across
social strata and class interests. Local bodies offer
today the only hope in benevolent, decentralized
state presence, where the centre may hold and the
peripheries may continue to define the political
spaces.
Conclusion
The sharp gender, poverty, caste lines and the
scarcity of resources make the need for extensive
field co-operation an urgent matter. Communi
cation is quite central to the effective success of
programmes in public health. Health workers are
the central agencies of the policy framework being
materialized on the field and often this is a
neglected fact. Barefoot health workers, centrally
involved in communication, are often shoddily
treated in their working conditions, creating a
tremendous demoralization in programmes. Par
ticularly in preventive work, information dissemi
nation and communication, and in pressurizing
the inflexible medical bureaucracies to extend
support in implementation, NGOs today are
We live in times where the poverty of others is toler
ated and where women's lives, especially when they
are poor, are a devalued social goal. Clean water
and sanitation, universal primary education,
especially for girls, more effective distribution of
food and nutrition, the alleviation of poverty and
greater public awareness and participation in
health preservation and care are all critical com
ponents of genuine health and development strat
egies. Many challenges face public health policy
makers. Can universal care be afforded and
managed by the public sector alone? How can
appropriate fiscal, human resources, and social
systems be developed to achieve this goal? Could
decentralization of health policy help in this
process? How best can the public and private
sectors be made to interact to achieve better health
outcomes?
The time has come for governments to pay atten
tion to all models of health care and campaigns
which worked. This needs at regional levels both a
convergence of social principles and a divergence,
which may be necessary for ensuring local accept
ability and success - an approach which is united
on being empowering to all users, sustainable and
sensitive to unequal relations of power such as
class, gender and race. An action plan needs to be
common to both government and private health
care financing matching programmes, strategies,
financial outlays and exercises for dovetailing. All
frameworks need to be moving in the same direc
tion with predetermination of strategic entry
points. In tribal areas the most successful health
strategies included livelihood issues, food security,
literacy to enable the tribals to access their rights,
e.g. food provisioning etc. Approximately they fall
in the rubric of gender, class and may be judged on
the basis of effectivity and accountability. Strategic
interests and an overall framework cannot be oppo
making their presence felt. The work of NGOs is
sitional in character, as is often the case. The state
preventive, proactive, promotive and emancipa
tory. They have shown the strength of being
embedded in community survival issues. Their
ideas on information, education and communi
cation (TEC) cover a large number of problems
faced by the poor and by women.
services with their vertical structure need to be
interfaced with building horizontal linkages and
working with disprivileged groups. Participation is
a much used word but it is not something that can
be engineered by funding and policy determina
tions alone. Few donors even seriously consider
Co-operation in health strategies
57
Development 42(4): Negotiating New Health Systems
financing people-linking efforts, jointly evolving
approaches which involve all stakeholders.
Effecting changes which are visible is a chal
lenge. If we wish to take this challenge there is little
time left. The field conditions must recall to us the
unfinished agendas of existence, well-being, and
the central ethical tenets of caring for others.
Health must not be perceived as an economic good
58
and a private privilege alone. All social forces
involved in health in the next millennium may wish
to pledge and act on a principle which functions by
inclusion and not by exclusion. Health is a social
claim, and unless we pinpoint the gaps and find
solutions for the structural imbalances we cannot
create those dimensions which will carry forward
the necessary transformatory processes.
Note
References
1 We thank Hemalatha D. at Hivos
for all the valuable assistance in
the preparation of the longer
version of this article. For a more
detailed version of this article see
'Globalisation and Equity in
Health'. Technical Report Series
1.8. Bangalore: Hivos.
Forthcoming.
Chelliah. RJ. and R. Sudarshan (eds)
(1999) Income-Poverty and
Beyond-Human Development. New
Delhi: Social Science Press.
Sen. A. and J. Dreze (1996) Indian
Development: Selected Regional
Perspectives. New Delhi: Oxford
University Press.
Voluntary Health Association in
India (1997) Report of the
Independent Commission cn Health
in India. New Delhi.
Community Based Approaches to Health Care of Tribal and Rural People
Dr. H. Sudarshan
Introduction
Vivekananda Girijana Kalyana Kendra (VGKK) is a voluntary organisation, started in 1981
for the integrated development of Soliga tribal people in B.R.Hills. At present VGKK
provides health care to 20,000 tribal population in Yelandur, Chamarajanaga and Kollegal
talukas of Chamarajanagar District and Nanjungud Taluks of Mysore District. The tribal
people in the area were traditionally dependent on shifting cultivation, hunting and food
gathering for their livelihood.
Karuna Trust (KT) another Voluntary organisation affiliated to VGKK is covering the entire
population of Yelandur taluka (74,000) and Six-Gram Panchayats (50,000) of T.Narasipura
taluka.
In contrast to Institution based health programmes, the Community Based Health Programmes
are rooted in the community and ensure community participation. These are people oriented,
need based, decentralised, culturally acceptable and cost-effective health programmes.
Health Infrastructure and Human Resources
VGKK has a well-equipped base hospital at B.R.Hills with an outpatient clinic, laboratory, xray, operation theatre and indoor hospital. Karuna Trust has a Primary Health Care at
Gumballi, Yelandur Taluka. The health services are delivered through 3-tier structure: Village
health workers. Multipurpose health workers and Medical professionals. The strength of
VGKK and Karuna Trust are its committed cadre of Health professionals and Health workers.
Health Profile of Soliga Tribal People
Soliga tribal people seems to have lead a healthy life till they were displaced and their
traditional sources of livelihood were not taken away by the forest regulation which came into
force from 1978. Their major health problems are Sickle Cell Anaemia, Tuberculosis,
Pneumonia, Chronic Bronchitis, Snake bites and mauling by bears, Hypertension, STD and
HIV are very uncommon. We are yet to find a case of Appendicitis, Colonic cancer or a tribal
student with refractive error. The health status of tribal people living within the forests is
better than those who have been displaced from the forests.
I.
Innovative Health Programmes of VGKK
1.
Sickle Cell Amnesia Screening Programme
The Soliga tribal people suffer from Sickle Cell Anaemia. The Soliga population has
been systematically screened for Sickle Cell Disease (SCD) & Sickle Cell Trait (SCT).
Initially Dr. R..L. Kirk of National University Canberra, Australia, helped us to set up
the screening programme. At present 28% of the Soliga tribal people have SCT and 23% have SCD.
1
The SCD patients are treated at our hospital. The clinical manifestations of the SCD in
Soliga community are less severe when compared to the SCD patients in Africa. This
could be attributed to the high levels of Faetal Haemoglobin in Soliga patients. A
Longitudinal study to understand the behaviour of the Sickle Cell gene in the
absence of Malaria has been undertaken.
2,
Integration of Traditional Medicine
The Soliga tribal people had their own traditional health care system. VGKK has made
an in-depth study of their system, documented it and integrated it with Modern System
of Medicine. Their knowledge of Herbal Medicines and health practices like
conducting deliveries in squatting posture are being promoted.
3.
Training Tribal ANMs
As the non-tribal ANMs were not staying and working in tribal areas. Tribal girls were
selected and trained at Mysore and Madikeri Government ANM Training Centres and
then posted to remote tribal areas by creating new sub-centres. These ANMs are more
acceptable to the tribal community and they stay in the remote tribal hamlets. This
programme is being done in collaboration with the Department of Health and Family
Welfare, Government of Karnataka.
4.
Training of House Surgeons from MMC and JSS Medical Colleges
House surgeons from Mysore Medical College are being posted as part of their Rural
Health Training since 1990. Later JSS Medical College also started posting their
House Surgeons. During their postings, they are oriented to Tribal and Rural Health
programmes.
IL
Innovative Health Programmes of Karuna Trust
The major health problem in the rural population of Yelandur taluka are Tuberculosis,
Epilepsy; Leprosy, Mental Health and Nutritional anaemias.
1.
Community Based Leprosy Control Programmes
As Yelandur taluka was hyperendemic for Leprosy, Karuna Trust took up the Leprosy
Control Programme in 1987. More than 1200 Leprosy patients have been cured of
Leprosy (both PB and MB cases) and we are in the Elimination Phase of Leprosy
Control Programme. The prevalence of Leprosy has been brought down from 16 per
thousand to 0.2 per thousand. Karuna Trust has also taken the responsibility of
Rehabilitating all the Leprosy patient with disability.
2.
Community Based Epilepsy Control Programme
This was started in 1990 in collaboration with Indian Epilepsy Association, Bangalore
chapter. Hot Water Epilepsy, which is very common in the Mysore plateau region, is
being Studied, and patients treated free of cost. Dr. K.S.Mani, a well-known
epileptologist has trained Medical Officers and health workers in decentralised cost
effective and community-based approach to management of Epilepsy. The prevalence
and incidence and the natural course of Epilepsy are being studied. Drug trials with
two herbs have also been undertaken.
2
3.
Community Based Tuberculosis Control Programme
Tuberculosis control programme was taken up in January 1992. Community based health
workers, laboratory technicians and medical officers were trained by National Tuberculosis
Institute, Bangalore. Approach of supervised chemotherapy with emphasis on sputum smear
positive cases was started in our project even before the DOTS concept. At present more than
95% of the TB patients are taking full course of treatment and getting completely cured.
4.
Community Based Mental Health Programme
Community based approach to Mental Health Programme and integration of Mental Health
into Primary Health Care was undertaken since 1994. The Medical Officers and Health
Workers were trained by psychiatrists from NIMHANS. Emphasis is on early diagnosis and
treatment of all psychotics in the talukas.
5,
Community Based Eye Care
Emphasis is on early diagnosis of cataract cases by health workers and motivating them for
cataract surgery. Extra-capsular extraction and IOL surgery is being done at the Operation
theatre in B.R. Hills. Two ophthalmologists. Dr. Padma Prabhu and Dr. Vijaya Rao are
helping us in this programme. Prevention of blindness by Vit “A” profilaxis and early
treatment of eye infection and injuries is also part of the programme.
6.
Community Dental Health Programme
We are running a Dental Clinic at Yelandur with the help of JSS Dental College. Dental
Health Education and treatment of simple dental problems is done by health workers.
7.
Primary Health Centres (PHCs)
PHC (Gumballi) with three sub-centres covering a population of 12,000 in 14 villages was
handed over to Karuna Trust by the Government of Karnataka in July 1996. All the staff for
the PHC and sub-centres have been appointed by Karuna Trust. All the aspects of Primary
Health Care -preventive, promotive, curative and rehabilitative services are being
implemented. All the National Health programmes and Reproductive and Child Health
programmes are being implemented effectively. Integration of undertaken. All the health
indicators show that the health status of the people in the PHC area has improved
substantially.
8.
Community Based Rehabilitation (CBR) Programme
This Programme was started in 1996. This programme for disabled includes Health and
medical rehabilitation. Education, Economic rehabilitation. Awareness Building and
community organisation, prevention of disability and nutrition programmes. The special
features of the programme are: a) Involvement of Panchayat Raj Institutions b) Empowering
persons with disability to organise themselves c) Integration of CBR into Primary Health Care
d) To do Action Research in CBR.
3
9.
Diabetes Control Programme
This programme was started with the help of Dr. Munichoodappa and Dr. Prasanna
Kumar. We are collaborating in a research programme to study the prevalence and
incidence of Diabetes in rural and tribal areas. We are also starting the Diabetes
Control Programme for the entire population of Yelandur Taluka.
10.
WHO & GOI Sponsored Pilot Project at T Narasipur
A pilot project on “Empowerment of Rural Poor in Health” has been undertaken in
collaboration WHO and Ministry of Health, Government of India. Through
Participatory Rural Appraisal (PRA) technique, the rural poor are empowered to
manage their health by doing Microplanning and formation of Village Health
Committees. Both Karuna Trust workers and Government Health Workers are jointly
conducting the programme.
4
THE FOUNDATION FOR RESEARCH IN
COMMUNITY HEALTH - A CASE HISTORY
By
Dr. N. H. Antia, FRCS, FACS (Hon.)
Director
The Foundation for Research in Community Health
84-A R. G. Thadani Marg
Worli, Bombay 400 018
Telephone: 4934989, 4938601 Fax: 4932876/ C/o.2662735
E-mail: frchbom@bom2.vsnl.net.in
FRCH was established as a no-profit voluntary organization in 1975. Its aim was to study why
neither the public nor the private health sector could provide appropriate health and medical care to
the vast majority of our people whether the poor, middle class or rich. This despite vast increase in
manpower, infrastructure and financial inputs. From its inception, FRCH held certain basic premises
viz. 1) that health was a fundamental right of the Indian people and 2) health and medical function
should be undertaken by people themselves with appropriate support from professionals. It
additionally possessed the vision to distinguish illness care from health, which is determined by non
medical factors such as education, sanitation, environment, culture and economics.
The experience in a medical college and its hospital in the city of Mumbai revealed that almost half
the patients who sought help were residents of a nearby locality. This unnecessarily swamped the
expensive services of this specialized institution for minor day to day problems. It was also noted
that even many of the patients who came from distant parts of the state and country for specialized
medical care could have been treated adequately in their own taluka or district hospital. Many of
the specialized medical or surgical problems like leprosy and bums could also be treated in a far
simpler, humane and cost-effective manner if the available knowledge and technology were
modified to suit our people's and country's requirements rather than merely following the 'latest'
trends of the West.
If this was the state of affairs in a premier medical institution of our country, the question arose as
to what prevailed at the grassroot level where the majority of these problems actually originated.
The Preventive and Social Medicine Departments failed to provide any viable answers. Hence, a
couple of years were initially spent in observing the health problems of a typical rural area of the
Konkan in the North Alibag taluka across the harbour of this premier city. Observations during
weekend rambles in the villages and of the local public and private medical services revealed that
the major problem was poverty and its associated diseases. The public sector primary health centre
hardly provided any of the preventive, promotive and curative functions, while the private
practitioners provided unnecessary and even dangerous medication and injections even for simple
ailments like flu and diarrhoea, based on the profit motive. Despite being overloaded with work, a
couple of motivated MBBS doctors at the District hospital provided a remarkably efficient medical
as well as surgical care with the limited facilities at their disposal.
Not knowing the underlying cause nor having the ability to alleviate the poverty, the initial effort
was to see if the simple, cheap, safe yet highly effective available remedies for some if not most of
these common diseases could be utilized by the people themselves. Since 70% of the population
consisted of women and children and the majority of health problems affected them, thirty women,
one from each village of about a 1000 population, were provided this knowledge and technology
by a small team of social and medical workers supported by a very modest referral service. To our
surprise within 5. years these women were able to achieve many of the 'targets' set by the
Government for 2000 AD in the late 70's. Besides minor ailments, this included major problems like
diarrhoea, dysentery, malaria, tuberculosis, leprosy and even family planning. This helped us to
overcome our confusion between education and intelligence of semiliterate and even illiterate
women. This opened a new avenue for providing medical services at remarkably low cost. If
simple, safe and effective knowledge and technology was provided in a simple manner, village
women with their inherent social skills, intimate contact and high credibility within their own
community could be the best agents for catering to the medical problems affecting their community
leaving relatively few problems for professionally trained doctors of the private and public sectors.
The women were also informed as to when and how to use the available referral services.
As a result of this dramatic experience, FRCH was invited by the late J.P.Naik in 1978 to provide
the research component and secretariat for the ICSSR/ICMR report 'Health for All: An Alternative
Strategy'. This provided FRCH a unique opportunity to interact with some of the most eminent
doctors and social scientists of our country and discuss the possibility of utilizing such a
decentralized people based alternative model of health and medical care which differed radically
from the existing public as well as private sectors. This also introduced FRCH to a new dimension
for the study of health rather than mere medical technology namely the social, cultural, political and
economic factors, which underlie both health as well as medical care. This unique Report also
stated that over 95% of all health as well as medical care can be best undertaken at the 100,000
population (taluka/block) level, of which 80% could be within the villages themselves.
Nevertheless, this people based health care system would have to wait till the right political climate
(such as Panchayati Raj) would provide them the necessary power to implement what was within
their capability and self-interest.
The 80's were hence spent by FRCH in arriving at a better understanding of the difficulties and
problems of the then existing health and medical systems. A series of conceptual as well as field
research studies were undertaken to understand the social, cultural, political, economic as well as
medical aspects that affected both health and medical care. This included interaction with the
ICMR, ICSSR, and Ministry of Health and Family Welfare as well as with other NGOs, national
and international agencies including those nearer home like Ralegan Siddhi. Within this period the
key contributions of FRCH included a) influencing the adoption of the Community Health
Worker’s scheme b) compiling a profile of health care in India inclusive of health structure,
infrastructure, medical education, expenditure and outlay on health and family welfare in various
states c) preparation of health education materials for grass-root level workers and non formal
health education schemes d) analysis of medical and public health in several countries e) utilization
of tuberculosis as a disease model for advocating a new people oriented approach to control of
major infections. Many of these findings earned an international reputation and formed a basis for
what was to follow.
It must be mentioned that a unique advantage enjoyed by FRCH in such socio-medical studies was
the availability and close interaction with its sister institution, the Foundation for Medical Research
(FMR) a well-equipped research laboratory. Both these institutions working as an almost single
unit provided a unique opportunity to bridge the traditional distance between the laboratory and the
field for problems like leprosy, tuberculosis, diarrhoeal diseases and reproductive health problems
which can be best tackled only through a combined medical and social science research oriented
approach. The publications and joint activities that ensued during the 80s and 90s bear testimony to
an otherwise much neglected approach to health and medical care, currently followed more
systematically and with vigour.
With the advent of Panchayati Raj as a result of the enactment of the 73 rd Constitutional
Amendment, the major attention of FRCH in the 90s has moved to the understanding of the
implications of a decentralized form of governance in the implementation of various alternative
strategies for the development of the People's Sector especially in health which is one of the
subjects covered under Panchayati Raj. This has enabled FRCH to formulate a more detailed
theoretical model based with the help of practical experience gained in a five-year field operational
research study in a valley in Purandhar taluka of Pune district. In a carefully documented study
covering a population of 17,000 amongst 13-Gram Panchayats, seventy village women have been
trained in a wider concept of health than at Mandwa covering several aspects of rural development.
Several of these women have in turn demonstrated their ability to train women from different parts
of the country sent by organizations who also desire to undertake similar work at the grassroot
level. FRCH and its village functionaries have also helped in spreading this model in two districts of
Maharashtra as part of a WHO supported project.
FRCH is now imparting upgraded training for some of these village health functionaries to help
bridge the gap between the village and the available professional services at the tertiary level such as
the taluka hospital and health center. Termed as 'Sahyoginis' they are being trained to provide in
turn training, support and referrals to about 25 village functionaries who will work with each of
them as a team at about the 5000-population level. This field study has demonstrated the feasibility
of an alternative people's sector in both health and medical care which has several advantages over
the existing public and private sectors. Such a decentralised people's sector can provide a more
accessible, personalized and cost-effective service, which is accountable directly to the community
of which it is a part.
Such a Community Health Care System also has several other advantages. These include involving
the community in its own health rather than depending on an external service to be 'delivered' by an
impersonal public and profit-oriented private sectors. Since the majority of the staff consist of local
village women functionaries, it offers the potential for large-scale useful employment of village
women within their own villages, being a field which is highly labour intensive.
*
All this at a salary far lower than the excessively paid staff of a unionized bureaucratic topdown public health service subject to targets and transfers.
*
Another major gain lies in the demystification of medicine enabling more effective control
and use of both the public and private sectors.
*
Prevention resulting from intensive non-formal health education, together with early
detection, can reduce both suffering as well as the cost of health and medical care.
*
Above all, this provides a remarkably effective means for empowering women within their
own communities.
*
This would enable the people to justifiably demand the diversion of public resources from
the urban to the rural sector.
*
It would also enable them to divert some if not most of their unnecessarily expensive
expenditure incurred on the private sector to their own people's sector which operates
without the profit-motive.
It is estimated that such a people's health sector can provide an effective health and medical service
at about Rs. 175 per capita per annum as opposed to Rs.575 presently incurred in the public and
private sectors. This could also enable them to provide free health and medical care to the 33% of
the population that live below the poverty line and who now have to divert 20% of their meagre
household expenditure on inadequate and expensive medical care.
The Community Health Care system hence has the potential of providing a remarkably effective
medical care from the village to the people's own Hospital, with specialist services. FRCH now
seeks to demonstrate this on a larger countrywide scale.
Being a people's programme it is closely related to Panchayati Raj. For Panchayati Raj itself to take
hold, awareness of citizens and the community at large need to be established for inculcation of
accountability as well as bringing health into the mainstream of public focus. Hence, production and
dissemination of information at grass-root level is a key activity for FRCH for generating a people's
health movement as well as a nationwide network for health and health care. Interestingly almost all
the 29 subjects covered under the Panchayati Raj enactment impinge on health. One of the activities
of FRCH is hence the production and dissemination of information on Panchayati Raj and the 29
subjects covered under it. **
In all these efforts, FRCH enjoys the support of a well-established library and documentation center
and administration at its office in Pune. There is ongoing collaboration with state and national
institutions such at the Indira Gandhi National Open University, National Open School, BAIF,
ICMR, ICSSR, the Ministry of Health and Family Welfare, the Planning Commission, and the
WHO.
Comments on "Cose Study of World Bonk activities
in the Health Sector in India"
Presented at the Consultative Meeting on "World Bank Activities in the Health Sector in
India" at World Bank Office, New Delhi, on 9th August 1999
The Sector and Thematic Evaluations Group and the Operations Evaluation Department of the
World Bank (India) prepared a case study on the World Bank's Health - Nutrition - Population
program in India based on review of literature, sector and project documents and the a
proceedings of the workshop on "The World Bank's Role in the Health System in India" §
which included 9 papers commissioned by OED.
This note by some of us from the Society for Community Health Awareness, Research and
Action, Bangalore, a multi-disciplinary professional resource group working for the last 15 4
years supporting community level health action and community oriented health policies by $
the voluntary sector and government, brings to bear comments on this case study from a ;>
Public Health, socio-epidemiological; management; ethical; and public policy perspective - $
which are the disciplines represented among the four member group of the society, who $
studied the document.
§y.
We had a little over a week to study this document and in spite of a request were able to get
copy of only one of the nine commissioned papers! So our comments are based on a rather
rushed analysis of the document handicapped by the absence of access to the background |
papers from which much of the perspectives and conclusions included in the case study, are S
drawn. Notwithstanding this constraint we hope the concerns we raise will be taken seriously
by the Ministry of Health and Family Welfare and the World Bank India operations team.
We believe these are concerns that we along with so many other public health / community' »
health / health policy resource groups have been raising for over two decades now, but we are S
emboldened once again to do so -because for once the findings of this case study so strongly
endorse and support them. These comments are also based on insights that wre have with §
involvement with World Bank projects at Karnataka State levels in various ways.
|
We believe it is time that the Ministry of Health and Family Welfare at the Centre and State
and the International binding partners, particularly the World Bank Cwho is now the largest
lender in health, nutrition and population with the largest programme in India’) - who jointly |
conceive, conceotualize, operationalise and monitor such large collaborative projects on
behalf of the people of this country - (emphasizing "poor and undeserved and concentrating |
on children and mothers") took these concerns seriously.
|
■ I
This significant, rather short, but important Consultative Meeting could be a serious step m |
that direction However, a more detailed dialogue is required if these concerns must get |
translated into constructive policy change.
>>
Dr. Ravi Narayan
Dr. C.M. Francis
Dr. Thelma Narayan
*
Dr. N. Devadasan
Community Health Cell,
Society for Community Health Awareness, Research and Action,
No.367, 'Srinivasa Nilaya', Jakkasandra I Main,
I Block, Koramangala, Bangalore- 560034.
Phone : (080) 553 15 18; Telefax : (080) 552 53 72; Email: sochara@vsnl.com
£
I
Comments
The Case Study of World Bank Activities in the Health Sector in India brings together
findings from a variety of sources (mostly World Bank commissioned) and attempts a
comprehensive, critical, historical view of 23 projects undertaken by the Bank in partnership
with the Ministry of Health and Family Welfare at Central and State levels and to which the
Bank ‘'contributed over $2.6 billion plus studies and policy dialogue"
The case study is frank, introspective and 'as objective as possible under the circumstances.
Though inadequately referrenced even from the commissioned studies, and perhaps
representing sets of opinions rather than 'evidence based analysis' it is still a sobering
indictment of what the Bank claims to be the "largest Health Nutrition and Population
programme" funded by it.
Appendix 1 of this note lists out in the report's words key findings and conclusions producing
a rather disturbing, disconcerting scenario and a rather frank admission of failure, and
distortion. If a SWOT analysis were to be done on the case study -then weaknesses
would far outweigh the strengths; and threats / distortions far outweigh the
opportunities!
In the absence of access to all the commissioned studies and reports / documents quoted in the
report, it would be unfair to attempt a comprehensive review of the document, but we raise
the following comments, reflections and questions from a Public Health; Epidemiological;
Management; Political Economy; Public Policy and Ethical perspective, keeping an overview
of the overall partnership between MOHFW and die World Bank in mind and not addressing
just the nitty gritty. Some of these are endorsed in the case study. Others are derived from the
findings presented.
1. Public Health devalued
The whole partnership suffers from a disturbingly lack of 'public health1 competence and
perspective and this chronic lacunae does not seem to have been overcome even when the
claim "the Bank is now on the right track" is made.
Throughout problem analysis, project planning and formulation, there is a confusion
between
-
-
-
public health system and public health care system
between socio-epidemiologicai context of a problem and its economic or technomananerial context, the latter taking precedence over the former every time
the wider determinants of health status that need to be addressed by good pubhc
health is totally ignored (devaluation of nutrition is admitted but other aspects like
water supply and sanitation, transport and communication, environment pollution
have not been addressed and even health education in this report is put outside the
confines of the health sector.
The focus on the poor, the indigent and the marginalised which should be the central
focus of an equitous public health system is ignored or if present in programme focus
is ignored in programme implementation
In fact both 'epidemiology1 which is the sheet anchor of pubhc health and political
economy1 which should be a important part of problem analysis is totally ignored.
The regional diversities and differentials -now known for ? long term are ignored.
2
Between the generalist administrators who now manage India's Health System and
the 'economists and programme managers’ that advise them from among the Bank’s
staff and Consultants Public Health has been totally devalued and distorted both
due to a lack of public health orientation and public health competence among the
policy makers concerned.
2. Primary Health Care sidelined
The World Bank projects evolved and developed when the country began to take the
Srivastava (1974) and Kartar Singh report (1973) seriously; commissioned the
ICSSR/ICMR Health for All: An alternative strategy document (1981) after becoming an
enthusiastic signatory of the Alma Ata declaration; enunciated the National Health Policy
guidelines of 1982; the National Education Policy of 1986 and the National Education
Policy for Health Sciences in 1989. In addition, the ICMR initiated its review of
Alternative Approaches in Health Care (1976) and the Evaluation of Alternative Primary'
Health Care (1980). Preceding these documents but supplementing / complementins
them, there was a spate of micro-level and collective initiatives in Alternative Health Care
in the 1970s and 1980s which are now well documented and a host of very incisive,
evidence based, thought provoking analysis of India’s health care systems from social,
economic, cultural, political, epidemiological and public policy perspectives from the mid
1980s to date. The World Bank project partnerships seem to be totally *uninformed'
about ail this and has not only ignored the Primary Health Care mandate but has actively
distorted the Primary Health Care agenda by focussing on
-
'selective, cost effective treatment schedules' rather than enabling / empowering
health care processes
relying only on the now well debated and well established inadequacies of the GBD
study based on DALYS (WDR - 93 and the documents thatfollowed)
focussing now on secondary hospitals rather than primary health care
on first referral units rather than the Primary Health Centres
totally neglecting the people and community, whose involvement at all levels was
envisaged by the Alma Ata commitment and 'whose needs / capacities / aspirations
were to be emphasised' and not made subservient to needs of technology or the
exigencies oftop down management systems.
Finally, it ignores Panchayatraj, which has to be the focus of Public Health and
Primary Health Care in the 1990s (even cautions against it) and then creates
Registered Societies as a decentralization initiative without clarifying how they will
be made accountable, transparent, responsive to public need or the country's
democratic political system.
3. Unconstitutional partnership
The World Bank seeks to influence / health policy in India by (a) virtue of being the
largest lender to the sector, even though there is enough evidence that this forms a small
part of the entire country’s budget; (b) by various conditionalities that overrule local
expertise and project formulations, (c) by thrustmg on the country ideas from rather
different countries with different social, economic, cultural, political, ecological and
epidemiological context. (An example from Malaria Control will be given to substantiate
this)
What is the 'Constitutional validity' of this leverage -which is greatly enhanced by use of
'funding muscle'? and which was established during a period ofeconomic vulnerability of
the country (The big break' mentioned in page 18).
3
Considering that many of these are loans and not grants, is the World Bank willing to
bear the costs offailure and distortions due to poor programme planning that ultimately
affect the poor the most?
What is the long-term sustainability of such a leveraged process - often arrogant, top
down and externally inspired. What is the effect on local health system capacity
development?
Is it not leading to coercion? Distortion? Competition?
Who will bear the
responsibility? What is the accountability and transparency especially to civic society?
The MOHFW must seriously dialogue on these issues before the PAC, the legal
system, the political system and civic society begin to question and initiate informed
citizens' action against it. In Karnataka this process is already starting up.
4. Ethical issues
The case study raises some major ethical issues
(a) What are the ethics of promoting so enthusiastically the 'private sector' when there is
no evidence even from Bank sources that the private sector either has the capacity to
provide 'low cost effective quality care' or has any commitment to 'public health' or to
the goal of equity (giving only the example of Apollo, Chennai, which is not even
among the best examples of corporate social responsibility is a case in point).
(b) What is the 'ethics' of undertaking a partnership taking the credit when there is
success and then pointing a finger at the MOHFW when problems are identified and
not solved (the report calls the World Bank position 'cautious' but 'incompetence' is
what the report establishes). Does this make World Bank an unreliable partner?
(c) What is the ethics of continuing to fund even after 1990 - a programme, when the
Bank is well aware of the flaws and distortions?
(d) What is the 'ethics' of expanding 'quantity1 at the cost of'quality1 or 'infrastructure' at
the cost of'services focussing on the poor1.
Is it at all surprising that ever since the World Bank has become a lender of large amounts
of money -that the medical scams in the country have also gone up? There may be no
cause-effect relations but why does the report ignore corruption which is endemic in the
country; is now well documented by civic society; and is well accepted in problem
analysis, by serious policy researchers.
Has the World Bank ignored it by oversight? Is it aware that it may be inadvertently
supporting it or even facilitating it - international tenders and guidelines not
withstanding?
5. Management issues
In terms of’Management' perspectives, it is rather surprising that a partnership that claims
to be able to marshall international expertise has continued to:
i.
develop infrastructure quantity rather than quality;
ii.
expected 'training' inputs to get over needs ofmanagement reforms;
Hi.
iv.
given so little thought to accountability and transparency;
relied on internal monitoring / evaluation by in-house staffand consultants rather
than independent credible external evaluation;
v.
ignored health human power management issues;
vi.
focussed only on 'userfee' rather than diverse find enhancing options including
health budget increase;
Vll.
given so little thought to ownership
Directorate of Health Service staff at all levels often feel coerced by the conditionalities
/guidelines and lack of flexibility, and do not identify with it. There is also nil ownership
at the community / civic society level.
(This is probably the greatest failure of the World Bank projects and both MOHFW and
World Bank partnership cannot overlook this any longer).
All this may be changing now - the case study claims - but is this real change understood
at core policy level?
6. Political Economy
The case study does not look adequately at the larger 'political economy’ issues against
which the analysis and the successes and failures should be contextualised. These include
the financial situation in the country and globally; the reduction / stagnation of public
sector budgets; the impact of rise in prices on drugs / diagnostics; the contraction of
public sector; the expansion ofprivate sector under LPG (Liberalization, Privatization
and Globalization) and its impact on public health and access by poor to medical care,
the potential impact of WTO and changes in Patent laws; the increasing corruption and
scams, etc., and thereby the policy researchers involved in the partnership constantly
under-estimate the political, social, institutional and other dimensions of the problem
analysis and hence offer recommendations that are general and not focussed on Tiow and
why things run’ or ‘do not run’. The report admits this and hope the next phase will
address it. While this may be changing, of late is it still on the sidelines of the
partnerships planning and problem solving efforts and depends very much on the quality
and experience of consultancies and in-house expertise that is facilitated both inside the
MOHFW and the WB-India office.
Unless there is a strong *public health policy resource group within the MOHFW1 in the
next phase and this free-lancing, free floating, adhoc consultancies and commissioned
studies are institutionalised a real change in competence may not take place. The report
establishes rather well the inadequacies of the last two decades but its chapter on
implication for the future or how to develop an effective programme fails to grasp the
complexity of the situation. One does not know whether this naievity is intentional or
inadvertent?
5
7. Building on strengths and new insights
While the above 6 comments may seem to focus mainly on weaknesses and distortions
that have plagued the framework of the World Bank Project partnerships, we do also
recognise some strengths and especially some of the new insights in the report which we
hope will find increasingly higher place on the agenda of problem analysis, project
formulation and project management in the future.
Some Strengths
1.
11.
By focussing on 'private sector' even though on the 'profit' rather than 'non-profit'
and 'corporate' rather than 'general practice', the Bank has brought into policy
focus the engagement with the private sector which has long been a 'blind spot1 in
Indian health planning. It is time the GOI / MOHFW studied this sector
recognized, monitored, involved, regulated, evaluated and 'quality assured' in this
sector.
It has more recently supported the target free approach and the shift from Family
Planning, especially sterilization, to Mother and Child Health (RCH) but still has
a long way to go towards women's health and development.
Some Ne^v insights
ill.
It has also identified the following new- thrusts in its section on policy
implications which are welcome
"need to focus on staff policies and practices regarding compensation,
assignment, transfer, promotion and demotion work rules and supervision”
"need to take more account of field conditions and to find solutions to
implementation problems”
"need to ensure that basic, simple services for the poor are not neglected in
the wake ofattention paid to secondary hospitals”
All these are definitely steps in the right direction. In addition, we believe that if the
points 1-7 are considered not as negative judgements but as stimulus to change track and
be rooted in local social reality than these will add to important policy change as well.
8. Some of blind spots, continue even after two decades of work in India, (a) One is
especially striking and that is the total disregard of Indian and alternative systems of
medicine and folk health traditions, in spite of the country having such a large network of
institutions, health centres and human resources in these systems, (b) Is the total lack of
understanding of people from a social / community point of view'. Reducing everyone to
a potential patient, client or stakeholder and taking about social marketing through LEC
rather than community involvement in planning, organising, monitoring and evaluation
continues and is another major lacunae.
9.
Our comments do not attempt a response to all the nitty gritty. In Appendix 2, we list out
an alternative framework of reference -a paradigm shift that is seriously required if the
World Bank and MOHFW want really to be on the right track. The Bhore Committee
recognised it in 1946; the WHO through Alma Ata in 1978, GOI in 1982 through the
NHP; and the ICS SR / ICMR earlier in their Health for All report in 1981;
How long can the poor and marginalised in our country wait for this shift to take place
in World Bank thinking. In the 1999, there is a some possibility - as seen in this report.
Will ’peoples health’ needs finally prevail over the ’market economy of health’? Will
ethical concern for health of the poor prevail over neo-Iiberal economics? Will the
World Bank partnership with MOHFW be willing to make this paradigm shift?
6
Appendix - 1
SOME FINDINGS OF THE CASE STUDY
1.
Bank Project 1972 - 1988
a. "the projects did not make significant differential improvement in project districts
compared to non-preject districts" (page v)
b. "Outputs other than infrastructure were largely neglected" (page v)
c. "No attempt was made to apply different delivery’ models in project districts"
d. "project districts continued to operate under the same personnel and recurrent budget
constraints.
2. TINP
a. "less successful in reducing moderate malnutrition"
b. "Programme experience seems to have been lost on India’ and with it the clear
emphasis on malnutrition as a leading risk for ill health".
3. ICDS
a. "Only modest positive effects" (page vi)
b. "targetting essentially by self selection" rather than as originally envisaged "targetting
of the poor"
c. "no Bank support for revision or structural change", (page 11)
4. Primary’ services
a. ’’efforts to improve quality have not accomplished much and it has devoted
inadequate attention to content, monitoring and evaluation, and feedback of
results”.
5. Before 1988
a. "Bank ill prepared to make practical, constructive suggestion for systems
improvements an alternative approach"
59-
6. Sector Studies 1988-98
a. "Tendency to make policy recommendation that are too general" (page 8)
b. "Tendency to draw judgements about facts without adequate comparisons to
experiences elsewhere" (page 5)
c. "Inadequate analysis of underlying political, institutional and sociological factors
that explain why things work the way they do" (page 8)
d. ■'Earlier studies tended to be designed and executed by Bank staff with limited
consultation" (Page 8)
7. IPP-VI &IPP-VII
a. "More success in expanding the delivery and training systems than in improving their
functioning"
b. "quality and performance of the training programme remained weak" (page 9)
c. "Efforts to strengthen MCH & IEC not very productive" (page 9)
d. "Little progress in shifting contraceptive mix” (page 9)
e. "failure to involve stakeholders in significant ways in design of project"
8. IPP-VIII (1992-97)
a. "The goals and design are appropriate and relevant but they are too new and
disbursing too slowly to judge their effectiveness or impact".
9.
CSSM (1992-97)
a. "Since many of the problems could have been anticipated the fundamental problem
was a weakly designed project, a factor that may have resulted from efforts to push
this project through quickly and make it quick-disbursing"
10. Specific Disease Control programs
a.
"Benefit-cost analysis and notions about which projects are appropriate for
public funding (eg., because of externalities, poverty or failure of private
providers) played hardly any role in selection".
b.
"Considerations about the proper division of labours between public and private
sectors never seriously entered the discussion"(page 12).
c.
"Risk of inadvertently introducing distortions in spending between diseases and
across regions" not considered adequately.
11. State Health Systems Development Project
a. "The projects did little or nothing to provide the other pre-requisites for an
effective referral system" (page 15)
b. "specific activities appear to have been selected opportunistically" (page 17)
c. "The type of monitoring and evaluation included in these projects even if
implemented well is not up to the mark for this purpose" (page 17).
12. Training
a. "Both government and Bank documents indicate an awareness of these problems, yet
the problems remain unsolved".
("Inadequate selection and training of trainers, course content not based on trainees
needs, insufficient time devoted to field work and practicing new skills, weak
management of training program, inadequate inservice training programs, lack of
programmatic guidance and leadership").
b. "Tendency to 'throw some training' to 'correct a problem' without thinking in
advance whether training alone will do the job".
13. IEC
a. "Bank's resources have done little more than help the government expand weak
and ineffective programs with the result that considerable resources have been
wasted".
14. Decentralization
a. Before April 1992
"No bank-fmanced projects included any decentralization initiatives".
b. "Local governments do not seem to be playing any significant role in the projects
investigated partly because their responsibilities are ill defined".
c. "A more widely used mechanism for decentralization 'Registered Society' has not
been evaluated".
15. Quality of Family Welfare Service
a. "Has been aware of the flaws in the system but has continued to find system
expansion and training programs despite their flaws and has not become
engaged with the person^? problems", (page 24)
16. Finally
a. "Bank waited too long to push project and studies devoted to ’health' rather than
'population'" (page 17)
b. "Nutrition has been undervalued".
c. "Since 1972, the bank has provided US$2.6 billion for 23-projects in population
health and nutrition - but
the problems persist, and partly for analytical reasons
and partly because the more promising projects are ongoing, there are few signs that
most of these projects are having a significant impact".
8
The Medical Poverty Trap
With Particular Reference to Asian Countries
Paper Prepared for the Bellago Workshop on
Developing Efficient and Equitable
Health Sector Strategies
July 3-7 2000
Myrtle Perera
A
Marga Institute
(Sri Lanka Centre for Development Studies)
July 2000
P.O. Box 601
93/10 Dutugemunu Street,
Kirulapone,
Colombo 6, Sri Lanka.
Phone: 94-1-828544/829013
Fax: 94-1-828597
E-mail: marga@sri.lanka.net
URL:http://www.lanka.net/marga/
Contents
Page
Introduction:
01
Section - 1
01
Defining the Medical Poverty Trap (MPT):
Section - 2
04
An Overview of the Poverty Causing Elements of Medical Care:
The Asian Perspective
Section — 3
06
Health-Poverty Nexus:
Implications of the Medical Poverty Trap
Section — 4
08
Country Case Studies
Section - 5
22
Conclusion
Appendix - A
Tables
24
Appendix - B
References
31
Appendix - C
Outline for a Future Study
32
Introduction:
Initially the paper was expected to summarise information and data from available literature
that would provide insights into the nature and extent of the burden of household expenditure
on health, on poor households. The study was to cover the Asian region in which countries
had to address the issue of ensuring access to health care by the poor in the aftermath of
economic reforms. Some of the countries had adopted mechanisms for health care financing
with user participation. Others maintained traditional systems of providing free health care.
Attention has been drawn to the way in which these systems function in providing health care
to the poor by some recent studies, notably in China and in Vietnam, that highlighted the
substantial burden on the poor resulting from payments for health. The report on Vietnam had
less empirical data than the one on China. There were, likewise, similar limitations in searching
and obtaining material in time for this paper. This paper has, therefore, been restricted to an
analysis basically of three situations, viz. China, Vietnam and Sri Lanka, and may be
considered in the light of an exploratory study. These three countries represent two systems,
China and Vietnam have introduced user charges whereas Sri Lanka has continued the
provision of free health care by the State.
Section
1
Defining the Medical Poverty Trap (MPT):
Some expenditure on health has always been a part of household expenses as shown in data
from the Consumer Finance and Household Income and Expenditure surveys. The health
reforms that were introduced in Asian Countries as part of the globalisation process and the
market- oriented policies that went with it have changed the pattern and quantum of this block
of expenditure. The escalation of household expenditure on health care was a phenomenon
that took place in all the post reform situations irrespective of the system of health care that
prevailed. Countries that introduced user charges for public sector health care without
effective exemption schemes for the poor have found that these add to the burden of poverty
on the one hand and reduce utilisation on the other. In countries in Asia such as China and
Vietnam that had free or subsidised health care prior to reforms, the introduction of user fees
has been described as a “sudden tax on those unfortunate enough to be sick and injured” (Prof.
Pham Manh Hung -1999).
The concept of cost-sharing itself was not unacceptable. But it causes concern when it affects
the poor adversely. Both Sri Lanka and Myanmar have not dismantled their free health care
system in the wake of reform - Sri Lanka, because of a political commitment that politicians
are wary of reneging on, and Myanmar because free health is within it’s political ideology. In
these two countries therefore the household expenditure on health would be that incurred
either, in addition to State health care or, as a result of constrains in the State health care
system. Moreover in countries in which health care is nominally free there is no provision for
safety nets for the poor. The health care expenses of households would add to the utilisation
costs of care such as transport, loss of work when health institutions have to be visited, and so
on. Asian countries contend with high poverty, the proportion of the poor ranging from 17
percent in Indonesia to 52 percent in Bangladesh (Table 1). Hence the need to pursue
investigation into an area that has the potential to increase deprivation in already deprived
communities.
A discussion on the MPT as defined above raises several issues. It needs to be viewed within
the broader framework of poverty and it’s linkages to health. The type of poverty trap that
immediately springs to mind is the cyclical effect of ill health on poverty. The household cost
of health care comes within this larger trap. An analysis of the MPT needs to get a handle on
the impact of the specific variable of health care costs on the economic status of the poor. It is
inevitable that when one tries to put a price on health the poor get further enmeshed in
poverty. They also get entrapped in ill health.
Household costs of medical care can change the health behaviour of the poor in ways that
could exacerbate the ill health trap and trigger the cyclical effects of poverty and ill health. The
poor if they are unable to bear the costs of health care, will avoid accessing care until the
situation reaches emergency status. If preventive services too are similarly affected then
preventable diseases add to the burden of ill health and contribute to poverty as well as impose
burdens on the national curative health system. The conventional arguments for cost sharing
are that, if health is not costed and paid for there is a wasteful use of health care services and
eventually the poor would be adversely affected. The poor in any case are unable to bear the
heavy costs of health care. The way in which these forces interact to affect the poor are
generally known but evidence is needed to assess the nature and intensity of the burden on the
poor. This paper summarises some of the evidence available from recent studies.
The data on the MPT facilitated the separation into categories of MPTs based on the types of
ill health and it’s care and the differential costs incurred. The household studies carried out in
the field in support of the Sri Lanka case study were able to provide a basis for categorisation.
The case studies highlighted a quality peculiar to the MPT- that is, it’s capacity to impoverish
the non-poor as well. This is an unexpected finding that is significant for all future studies of
the MPT and, in fact, for strategies for poverty alleviation.
The case studies helped also to discern two basic types of costs of medical care in two
situations that prevail, in addition to existing poverty. They are:
•
Cost borne by the household for a mix of common illnesses, - e g. recurring common
illnesses in children, and
•
Escalated costs owing to changing disease patterns.
A sifting of evidence as is done in this paper is a prelude to further investigation and research
that could guide and direct policy and strategies to deal with the phenomenon in it’s varied
manifestations. The discussion in the paper touches upon several aspects that impinge on the
MPT and have been referred to in the issues raised in the foregoing section.
The rest of the paper is organised as follows:
Section 2 identifies the poverty causing elements of medical care. The indirect impact
of external phenomena such as globalisation and structural adjustment and internal changes
such as the health transition that have relevance to issues related to poverty and health care
have been discussed.
Section 3 examines the health poverty nexus within which the MPT is placed.
Section 4 documents evidence of the MPT as manifest in 3 countries. In China and
Vietnam the MPT is a consequence of the introduction of user charges while in Sri Lanka it is
a result of constrains and weaknesses in a free health system.
Section 5 gives the conclusions and discusses the issues that would have to be faced in
formulating a National Health System that has the capability of dealing with the MPT in it’s
varied forms.
Method:
The literature on China provided analytical reports of the impact of new health policies on
health expenditure. Reports that analysed findings from a survey on medical expenditure in
households in thirty poor counties in China, were used in this paper to support the case study
on China. The paper on Vietnam discussed the impact of health reforms and introduction of
user charges in more general terms while it's main focus was on strategies that could address
the weaknesses in the system.
The case study of Sri Lanka puts together data from a series of three Consumer Finance
Surveys of the Central Bank of Sri Lanka for the years 1981/82, 1986/87 and 1996/97. Only
the preliminary tables were available in respect of the last survey in 96/97 since the report is
not yet published. This data was supplemented with relevant data and information from other
published and unpublished documents on Sri Lanka. All documents used for the paper are
listed in Appendix B at the end of the paper.
Section
2
An Overview of the Poverty Causing Elements of Medical Care:
The Asian Perspective
Asian countries have a tradition of treating medical care and health services as a social
responsibility of the State. The health systems that prevail in Asian countries range from totally
State provided to variations of subsidised health care.
The way in which the health and social sectors evolved to achieve the varied health conditions
that prevail in the region also contained features that are relevant to a discussion on the
household burden of health expenditure.
Analytical writing on the health sector and health delivery systems in Asia refer to the wide
variety of systems and their outcomes in terms of health indicators that span the countries in
Asia.
ccHealth Care in Asia” - a World Bank publication- (1) contains a useful comparative analysis
of country experiences in health. The study, analysing the economic links with health status,
makes a significant observation based on experiences of countries such as China, Myanmar
and Sri Lanka. It underscores the experiences of these countries as they demonstrate that
appropriate policy decisions in social sectors coupled with judicious allocation of government
resources could overcome limitations in the quantum of national expenditure on health in
achieving significant gains in health status. They have, moreover, combined those gains with
relatively equitable distribution of health care.
The figures in Table 1 of key demographic and health indicators for selected Asian countries
demonstrate that, although all Asian countries have made great strides in improving health
status over the last three decades, some have advanced further than others and those that did
so were not necessarily countries that had high per capita incomes and a steady economic
growth.
The specific nature of the health problems that prevailed in these low-income countries and the
manner in which these were managed could have contributed to their achievements in health.
The dominance of a set of communicable diseases that were the main causes of death and
disease in nearly all Asian countries at that time, enabled State health systems to build and
strengthen vigorous outcome oriented public health programmes that were also cost- effective.
Countries that progressed more than others in health indicators had combined such
programmes with other non-health socially progressive policies for the provision of basic
needs. These successes have been achieved through recognition of the intersectoral nature of
health and the need to adopt a holistic approach in dealing with health problems. These were
the conditions that prevailed in Asian countries when structural adjustment programmes were
initiated.
Impact of Structural Change:
The rapid changes that assailed the social and economic sectors of Asian countries,
significantly affected or altered the trajectory of performance in their health sectors.
Nevertheless the response of countries to the changes as they affected health care differed
significantly among countries in the region. Countries such as Sri Lanka and China that had for
long periods maintained very cost-effective health delivery systems on low incomes and low
national spending on health were increasingly called upon to face the challenges of continuing
these policies and programmes in the wake of the critical changes within the health sector
itself. These challenges related to issues of both cost and accessibility to health care in the
context of new health hazards and new patterns of morbidity that demanded different and,
often, costly interventions. Policy decisions in this context had to face the demands of equity
and efficiency as well as of affordability.
The onslaught on the health sector came both from within the countries themselves, as a result
of the achievements in health status, as well as from pressures for economic reforms and
market- oriented policies that flowed from globalisation and the accompanying liberal trade
policies. Each of the Asian countries had its own time- table for change and the paradigms of
change differed according to the different political ideologies and structures that were in place.
Discussions in the literature of the 1990s explore the links between the degree of progress in
health outcomes, the success with which they overcame the health consequences of the
communicable diseases and, the nature and extent of the burden of illness that arose from an
imposition of the new illnesses. In view of this link the ‘‘double burden” of disease appeared to
differ in its nature and composition in different country situations.
The Impact of the Health Transition:
The nature of the health transition that took place in Asian countries in the 1990s has been the
subject of several discourses related to health. Countries that experienced this transition had
reduced fertility levels considerably and were facing the phenomenon of a rapidly aging
population with its attendant implications for dependency and old age care. Their concerns
extended also to the increasing costs of medical care that were necessitated by the changes in
disease patterns. These new diseases require long term and expensive care, use of new
technology practised in the developed countries and which spread very rapidly to the less
developed countries through the vibrant information network, and a cost burden which
governments in low income countries are unable to bear. The concept of health as a social
good and the State’s mandate to provide health care to all was being vitiated. Countries such
as Sri Lanka and China that had progressed furthest in the demographic transition but had the
communicable disease burden to reckon with faced the dilemma of maintaining responsibility
for health which involved provision of expensive care within the tradition of free health
services.
Writings in the 1990s discuss the effect of the health transition on Asian countries and the
implications of the double burden of disease and mortality. This dilemma is well documented
in a paper (2) that cites ten leading causes of death in 1990 in developing countries. The study
points out that seven of these diseases are communicable diseases. In contrast in developed
countries the non- communicable diseases account for about 56% of all deaths and
communicable diseases, for only about 4%. In the developed countries therefore the total
effort of the health sector could be devoted to the health care demands of the noncommunicable diseases.
These changes had implications for the use of best practices or models that other low-income
countries had been able in the past to emulate. The low income countries (such as Bangladesh)
that could have emulated countries such as China and Sri Lanka, in dealing with the burden of
communicable diseases could do so no longer because of the distortion in the health scenario
in Sri Lanka and China that had been caused by the entry of the non-communicable disease
burden. They therefore had lost their role models and were left to look for their own solutions.
Section
3
Health-Poverty Nexus: Implications of the Medical Poverty Trap:
The 1990s witnessed the emergence of analytical literature that explored health - poverty links.
They established a circular link between the two. The institutional mechanisms for poverty
alleviation within the Asian countries were based on the assumption that the health -poverty
nexus could be best addressed within the programmes for poverty reduction. Pressure for paid
health care appears therefore, to have been justified in some countries (notably Sri Lanka) on
the basis that such generic measures that aimed at providing financial relief to the poor would
likewise act as safety nets to ease the burden of health expenditure.
Other countries,
however, argued that user fees would contradict the paradigms of development they had
adopted.
The manner in which health policy and macro policy interacted to deal with the totality of
social problems in Asian countries could indicate the feasibility of providing a niche for MPT
within programmes that are expected to enhance the capability of the poor to cope with and
alleviate general deprivation. It could provide an understanding of why Asian countries can
benefit by focussing specifically on MPT. The argument presented is that given the
background of holistic social progress in most Asian countries, MPT, if left to grow, could
creep in unnoticed and vitiate the gains of decades of progressive policies. Furthermore, the
MPT could become a missed out variable of poverty in measurements of poverty. This then
could be the rationale for examining its corrosive role in Asian societies and taking timely and
effective measures to counter its effects.
A study (2) encompassing the SEARO countries provides an analysis of their health sectors
and their progress. The MPT placed against this background is a phenomenon that should be
recognised as one that can erode the gains in social indicators presented in Table 1. In that
table, depending on availability, the data is given for three points of time i.e. the 1970s, 80s
and 90s. The trend over this period shows that all countries have improved their health related indicators. The key indicators of maternal and infant mortality and fertility have
dropped considerably- dramatically in some- while life expectancy has risen. The point that is
made in the SEARO study, however, is the persistence of poverty and deprivation in the
region in the context of the rapid advances in health conditions. The general poverty
conditions in the region are indicated thus.
•
Nearly 45% of the adult population are illiterate,
•
Nearly 80% of the population have an average life expectancy which is very much
lower than the average for industrialised countries,
•
40% of the regions population are in absolute poverty,
•
Between 63% and 66% of children under 5 years of age are undernourished in the
countries of the region, which are the most populous.
The SEARO region does not include China and Vietnam. The data for these have been added.
They highlight the negative features that Asian countries have yet to grapple with in their
journey towards a healthier more progressive society.
This document and others have analysed the skewed relationship between government
expenditure on health and the achievements in health indicators. The MPT could be examined
in this context as well. The relationship between public expenditure and the MPT is examined
in the analyses of government budgetary allocations for health. The disparities in public
expenditure on health in the countries of the region show the absence of a clear nexus between
state expenditure and progress in the health status. Public expenditure on health as a
percentage of GDP is low in Thailand (1.1%) and Indonesia (0.7%) where it is mainly spent
on public health programmes. It is high in Sri Lanka (1.8%) and highest in Nepal (2.2 %). But
Sri Lanka finances a free curative and preventive health care system, while in Nepal the cost of
health care delivery is relatively high. In Sri Lanka health indicators are high and are showing
remarkable progress while in Nepal initial health indicators remain low.
Another study on Health Financing in Asia- World Bank (1) shows the relative per capita
expenditures on health by the government among the poorer countries. It cites the experiences
of China and Sri Lanka and their success in health improvements with per capita government
expenditure on health (11% in China and 9.2% in Sri Lanka) similar to that of India (12.5%)
and Indonesia (10.4%). But both Sri Lanka and China have attained a female life expectancy
that is many times more than India and Indonesia and an IMR that is considerably less. In the
pre-transition scenario, therefore, government expenditure did not surface as a pre-condition
for health achievement. What then were the pre-conditions if any? The SEARO study
addresses that question.
It observes the “simultaneity of progress” where the “progress of each indicator requires
simultaneous advancement on a whole range of other social and economic indicators. The
deviations from the trend (e g. high poverty and malnutrition) are equally illuminating in that
they demonstrate how lack of progress in any one indicator affects the total level of well
being”. (2).
Be that as it may, there is evidence that illness and the inability to prevent it or to obtain
appropriate and effective treatment can cripple a household despite the advances in other
aspects that it has achieved. The MPT as a phenomenon is seen to have over arching
consequences in eroding household capability over and above its role as a single indicator
within a host of other health and economic indicators.
The two case studies that follow provide evidence of the nature and impact of the MPT on
poor communities in Sri Lanka and China.
Section
4
Country Case Studies
Impact of Health Reforms on the Poor
Cost Sharing
The policy shifts that attempted to meet the changes that arose from health reforms generally
veered towards the provision of economic solutions. The pressures for the introduction of paid
health care as part of health reforms have been addressed in various forms by the different
countries in Asia. Myanmar and Sri Lanka have resisted these pressures and continued with
free health services by the State. Others such as Thailand China and Indonesia have introduced
different formulae for cost sharing by the provider and the consumer. Two major types of
cost-sharing mechanisms commonly used are the system of charging user fees in public health
institutions and health insurance. The majority of the countries in Asia have adopted variations
of these two.
Many of the writings that advocate user fees argue their efficacy in enhancing equity and
efficiency - a ploy for which many Asian countries fell. More recently, however, a few studies
carried out in China and in Vietnam and other reports have revealed the adverse effect they
have on utilisation of health services by the poor and on equity. The introduction of cost
sharing in other forms such as insurance has given rise to other problems such as wasteful use
of drugs, inappropriate selection of treatment and medication and issues of moral hazard, thus
distorting the health care scenario of the country.
Analyses of country experiences (3) point out that particularly in low-income countries where
public expenditure on health has fallen “the quality of services have deteriorated, utilisation
levels in rural areas have declined and outreach services no longer function”. The general tenor
of the discussion in these reports is that the introduction of user fees ha in many cases been
followed by sharp declines in service utilisation.
Countries in which the communicable diseases form a large part of the disease burden and
where the Primary Health Care (PHC) system has been the backbone of the health sector for
the poor, had perforce to impose user charges on this system as well. Literature suggests that
PHC not being immediately profitable should continue to be the responsibility of the State
even after health reforms.
The Chinese experience provides evidence of the break down in the low-cost community
friendly systems that had effectively provided health care to the poor when these were
replaced with paid systems. The poor were therefore directly affected. There had been a
premise that diseases that require costly care affect the affluent more than they affect the poor
and that the poor are, therefore, largely shielded from the high cost high technology care
regimes. This premise has been proved incorrect by evidence from Asian countries (4) where
non-communicable diseases have featured substantially in the morbidity and mortality of the
poor. Such findings have spurred on the recent concerns that are surfacing on the likely
poverty causing effects of household expenditure on medical care.
Case Study of China:
Impact of Health Reforms on the Health Situation
Information was obtained primarily from two documents (5 and 6). A conscious social policy
within a planned economy had resulted in great strides in improving health indicators. This
was achieved with relatively low expenditure on health care. Costs of health care were
contained at just over 3% of GDP in 1981. Life expectancy which was 40 years in 1950 rose
to 69 years in 1982 and 70.5 in 1992. Infant mortality registered a steep decline from 85 in
1970 to 44 per 1000 in 1982.
Another noted achievement was the high insurance coverage (up to 90%) under the Rural Co
operative Medical System. The Epidemic Prevention Service that delivered public health
programmes was able to reach the rural periphery with extended disease control programmes
financed from the provincial budget.
The 1978 economic reforms had significant repercussions on the health sector. Two key
changes that had long term effects were the break down of agricultural collectives that led to a
virtual dismantling of the Rural Co-operative Medical Scheme, thereby reducing insurance
coverage to only about 10% of the rural population. The second was the government
encouragement of health programmes and facilities to rely on user fees.
The extent of the burden of payment to the poor is indicated by the findings of the survey of
30 counties in China. It states that those with an income of under 250 yuan per month paid
23% of that income on health services and that too with low access to and utilisation of health
care. The shift of the economic burden to the poor is seen also in that only 11% of the income
was spent on health care by high- income earner households i.e. with incomes between 430
and 690 yuan per month. An average hospital admission cost 60% of the annual net income of
a poor household.
The primary health care system implemented under the Epidemic Prevention Service had
provided the preventive safety net for the poor by reducing the incidence of a wide range of
communicable diseases that could impair the economic capability of a poor household. The
introduction of user fees charged by village health workers resulted in a reduction of the
coverage of immunisation and in the reach of TB control services to the poor. Outbreaks of
epidemics of communicable diseases have been traced to the weakening of the PHC work and
the diversion of Public Health workers to activities for which they can charge fees.
The village level health facilities suffered from a dependence on revenue generation from
consumers for maintenance of the physical infrastructure and for payment of health workers.
The consequences of the loss of access to the rural health facilities were severe on the poor
who would then have to travel further at added cost to obtain health care. Under these
conditions the health seeking behaviour of the poor was affected in several ways as found in a
survey in 1993.
•
60% of persons referred to a hospital were deterred from accessing one owing to high
cost.
•
Among the seriously ill 40% in rural China had not sought medical assistance because
of excessive costs.
•
The incidence of infectious diseases among the poor was three times higher than
among the rich. But 33% of the poor failed to access health care as compared with
only 16% of the rich.
•
The poor spent only half the required time in hospital to save costs.
The implications are that the poor are likely to have carried the burden of illness not fully
cured, back to their homes.
Impact on Health Indicators
The annual growth rate of GNP (9.8% in 1978-94) in China was not reflected in it’s health
indicators. The under five mortality that declined steadily for 40 years appears to have levelled
off in the mid-1980s at about 44 per 1000 live births. A growing difference between poorer
areas and major cities in China which in 1992 was more than 4 times (72% in rural areas and
16% in major cities) (6).
Some health status indicators speak for themselves. Among the rural poor;
•
90% suffered from worm infections
•
50% of children at or below the poverty line are mildly malnourished
•
the poorest quintile has an infectious disease rate three times that of the richest
quintile, and more than twice the IMR
•
1/3 of low income households seek no health care
•
People in the lowest quintile make only 60% as many health care visits as those in the
highest quintile.
The poor in China, according to World Bank criteria, amounted to 350 million in 1996. The
question of who actually pays for health in China is a mounting concern with the share of
government spending declining from 32% in 1986 to 14% in 1993 (excluding government
insurance). The insurance from the rural co-operative medical scheme had fallen from 20% in
1978 to only 2% in 1982. As against this private health expenditure grew ten times in this
period while out-of-pocket payments are stated to have risen from 20% of health sector
revenue in 1978 to 42% in 1993 (6).
Analysts of the Chinese health system cite the uncoordinated financing, pricing and
organisational policies as being responsible for “a serious dissonance in the system”. These are
alleged to have resulted in distorted medical practices such as overuse of drugs and high
technology tests creating in turn more inequities in access for the poor as compared with the
rich. At a national level there did not appear to be a measurable decline in the level of health
status of the people. Nevertheless, the report underscores that the changes had not produced a
commensurate improvement in health status (7). The declines however, have been shown in
the empirical micro level studies and have been cited in this section.
Case Study of Vietnam:
The paper (8) that was available on Vietnam dealt only in a general way with the impact of the
Doi Moi reform process in Vietnam on health and costs of health care. The pre-reform health
status has been described as a model - at it’s level of income- of a highly cost effective system
particularly for PHC services at the commune level.
One health indicator that is very significant is that it has an 11 year longer life expectancy than
the average life expectancy of low-income countries. This statistic is compared with China,
which has only eight years longer than this average, and Sri Lanka, which has only six. This
indicator could well reflect the health status of the population at the national level, and this
was a product of the pre-reform health care system.
The paper deals primarily with the distributive inequalities that affect the health status arising
from the inequitable access to health care and constraints on it’s utilisation by the poor
because of excessive costs. Series of household surveys conducted by the Ministry of Health
from 1995 to 1998 reveal an increasing trend in difference between utilisation of PHC by the
rich and the poor groups. The difference is found to be around seven fold.
The poor in mountainous provinces are worse off than the poor in the Delta area, according to
a study in 1997. Utilisation of public health facilities by the poor in mountainous areas was
only 3.4% per year as compared with 25.9% by those in the Delta area.
Another survey in 1993 highlighted the differences in expenditure between the highest income
groups and the lowest for health care. For outpatient care the difference was 2.3 times while
for inpatient care it was 3.9 times.
The impact of user fees has not been fully examined in Vietnam. However the paper makes
some deduction based on the way in which user fees operate in the current system. The
unregulated market for drugs, it is pointed out, can lead to uninformed use by those who
choose self-care because of high cost of accessing delivery points. At the delivery points
although people who are unable to pay are seldom refused care, it seems likely that those who
do not pay have less “comprehensive” medical treatment according to the paper.
The system as it operates affects the quality and level of services provided by health facilities.
This occurs in the system in which government is expected to cover losses from non-paying
patients. This is provided for only about 2-3% of population while in fact about 30% of
patients are fully or partially exempted. This affects the quality of services in poor dominant
areas.
These are some of the ways in which the burden of the poor is increased and poverty
exacerbated through the system of user fees as it functions in Vietnam. The paper focuses on
strategies to correct the situation or as much of it as is known from the few studies done so
far.
Case Study of Sri Lanka:
Concern about household expenditure on health care that can impoverish, has not emerged as
a significant issue in health sector analysis in Sri Lanka even after the economic reforms which
were adopted in 1978- much before other countries in South Asia, but along with East Asian
countries. One reason for this is the continuing provision of free health for all in Sri Lanka,
and the assumption that government health care is still capable of meeting all the health care
needs. There are several features that place Sri Lanka apart within the Asian region in terms of
the achievements in health so far. The differences can be attributed partly to the health policies
that determined the structure and management of health services and contributed to the health
outcomes, the management of the health reforms in the context of economic reforms and the
nature and composition of the health transition in Sri Lanka.
The Health System
Free health care encompassed both preventive and curative care through a widespread
network of multi-tiered facilities that are spatially distributed to reach the rural periphery. They
provided both western and ayurvedic care. A private health system operated mainly for
ambulatory fee-for- service care with a few facilities for in-patient care in the main urban
capitals. The increasing demand for private facilities has resulted in an expansion of private
hospitals in the last five to six years (9).
Health Outcome
The result of over half a century of investment in social capital is demonstrated in key
indicators of low mortality and fertility. In the 1990s the MMR was less than 1% per 1000 live
births and IMR was 17; life expectancy had risen to 74 years for females and 70 years for
males; female literacy was a high 85; the net reproduction rate has now reached 1 according to
the DHS 1993. These were achieved with a GNP per capita of less than USS 600 in the 1990s
(2).
The health transition that occurred as a result of these changes has been more dramatic in Sri
Lanka than in other Asian countries, and the policies had to be geared to managing this
change. Neither economic growth nor policy changes could keep pace with the rapidity with
which the consequences of the health transition changed the need and demand for health care.
The system continued to be geared to maintain its old services while it introduced few
measures for emerging health problems.
As stated in the SEARO study, by the early 1990s ischaemic heart disease, cerebrovascular
disease, diseases of the pulmonary circulation and malignant neoplasms had ranked first,
second fourth and eighth among the ten leading causes of deaths in hospitals (fig.l in next
page). More significantly as seen in fig. 1, these diseases were within the leading causes of
death in remote poor districts in the country while the facilities for their care were
concentrated in medical institutions situated in the capital Colombo or in a few major hospitals
in the provinces. This positioning of facilities was governed by a concern for economies of
scale. Equity of access had to be sacrificed for cost efficiency (10). Sri Lanka has been tardy in
recognising and responding to the new needs in health care. There is a general recognition of
the deficiencies of user charges, of insurance and of targeting. But there does not appear to be
a conscious effort to look for feasible alternatives within the paradigms of development that
Sri Lanka has subscribed to over the years in the context of the poverty and health conditions
that prevail.
Future health policy reforms do not include the introduction of user fees. In 1971 the
government introduced a token fee of twenty-five cents form outpatient first visits to public
health institutions. This had immediately resulted in a 30% drop in utilisation. The assumption
was that the frivolous visits would have been effectively curtailed. It was never investigated to
find out the extent to which genuine users were prevented from using the facility. Be that as it
may, a study (9) points out a very interesting outcome of this measure. This was the long-term
effect of a decline in the rate of outpatient visits that has continued even up to the 1990s. The
measure appears to have triggered an abiding change in health seeking behaviour. This would
bear out the assumption that a considerable element of wasteful and frivolous use did prevail
in the Sri Lankan situation.
The Task Force on Health Reform has instead of introducing mandatory user fees suggested
voluntary payments by consumers. Nevertheless, the strain on public financing has raised
questions of quality of care in public facilities and the increasing practice of passing on some
of the services to the consumer .by indirect means such as prescribing drugs to be purchased
outside and diagnostic tests to be carried out in private institutions. These are viewed as
attempts to encourage the use of private sector facilities by choice. But the effect on the poor
who have no choice needs to be monitored.
Health Care Costs
Government Spending: Looking first at government spending, evidence from budget
allocations for health from 1987 to 1992 show a decline in allocations as percentage of GDP
from 2.09 % in 1987 to 1.6% in 1992 (16). Figures for 1980 and 1990 show a drop in
government spending from 1.7% of GDP in 1980 to 1.6% in 1990 with a commensurate
increase in the share of household expenditure from 1.3% of GDP in 1980 to 1.7% in 1990.
(9).
A study on Resource Mobilisation for Health (9) among others analyses the distribution of
finances in the health sector. Government outlay for the health sector has been modest,
between 3 and 3.4% of GDP over the past three decades. The rapid health transition has been
achieved with a total public spending of less than 2% of GDP and US$ 5 per capita per year
(Rannan-Eliya). Household spending on health care has shown an increasing trend and
currently is thought to exceed 60% of national health expenditure (9). The absence of user
fees, it is seen, does not reduce the indirect non- stipulated costs of health care to a household.
Fig: 1
Ischaemic Heart Disease - Movement Within the Ranks In Districts,
of the First Ten Leading Causes of Hospital Deaths.
District
1 Colombo
2. Gampaha
3. Kalutara
4. Kandy
5. Matale
6. N. Eliya
7. Galle
8. Matara
9. Hambantota
10. Jaffria
11. Kilinochchi
12. Mannar
13. Vavuniya
14. Mullaitivu
15. Batticaloa
16. Ampara
17. Trincomalee
18. Kurunagala
19. Puttalam
20. Anuradapura
21. Polonnaruwa
22. Badulla
23. Monaragala
24. Ratnapura
25. Kegalle
Household Expenditure on Health
This brings us to the central focus of this study- the burden of health expenditure on the poor
and its many faceted consequences for impoverishment. Several data sets are used in this
section.
The first set of figures from the Consumer Finance Survey series has been used to derive a
trend on household expenditure on medical care and this has been compared with expenditure
on food (Fig 2). While comparable figures were available for the years 1981/82 and 86/87 the
data for 96/97 was available only from preliminary tables. In all three the proportion of food
expenditure was derived for the lowest and highest income groups and are therefore
comparable. In the case of medical expenditure the 96/97 figures are based on income decilesthe lowest three and the highest three deciles have been compared (Fig. 3)
The other difference is that while the food expenditure is given per spending unit the medical
expenditure is per person. These differences however made no significant difference to the
conclusions that could be drawn on the relative positions and in assessing a trend. These
figures are shown in table 2.
The figures show that among the low-income groups food expenditure as a proportion of all
expenditure was around 70% for all three CFS periods (it had dropped to 68% in 96/97). It
fluctuated more for the upper income groups being 41 % in 81/82, 57% in 86/87 and 34% in
96/97. These figures show the very limited resources that were available to the poor for all
non-food items including medical items. The upper income groups were not so constrained.
When it came to per capita medical expenditure the differences between the low and high
income groups were much smaller. In 81/82 it was only 0.4% and in 96/97, 1.1%. The
magnitudes were higher for the upper income groups but the proportions spent would have
left little for the poor groups for other essentials.
The per capita medical expenditure by type of care in 96/97 showed that a disproportionately
high 78 % of was spent by the poor on western drugs and medical tests as against 54% by the
rich. The trend in the proportions spent on this category was an increasing one for the lower
income groups, while it was decreasing for the upper income groups. The rich spent a higher
(19%) proportion on hospital charges compared to only 3.2% by the poor. Proportion wise
both categories were close in their spending on western consultation fees i.e. 7.2% by the poor
and 9.4% by the rich. Both the poor and the rich paid for charms higher proportions than they
paid for ayurveda consultations and for ayurveda hospital charges. (Table 2).
The next set of figures from a Report on Health Strategy Financing Study of the World Bank
(11) analyses health care costs from a special survey in four districts. A sample of nearly
12000 persons who reported an illness in the past month was studied.
According to the findings of this survey, in general the magnitude of out-of-pocket
expenditure on illness increases with income, the average for the lowest three deciles being
SLR 78.90 per illness while for the highest three deciles it was SLR 207.92
This study also looks at the burden of illness in terms of economic costs on the poor by the
mean health care related expenditure for populations below and above a poverty line of SLR.
471.20 per month. The population in poverty on this basis has been estimated as 41 % of the
sample. The figures are in respect of ill persons only as a mean expenditure per episode of
illness in the four weeks prior to the survey.
A summary of the findings showed;
• The mean monthly expenditure was SLR.273 for the poor and SLR 879.74 for the rich.
This works out to 59% of income for those on the poverty line.
• The expenditure varied with the facility chosen. For the poor the highest cost was for
ayurvedic care (Rs. 639.94) while care at the major state western (MSW) facility cost only
slightly less (Rs. 610.69).
• The poor on the average spent less on private western care (Rs 439.58)
Some key issues for policy formulation have been highlighted from these findings.
• Although health care is available at no cost to all persons, considerable sums are expended
for state health care as well.
• The urban ill incur higher out-of -pocket expenses than the rural ill but the latter will
spend greater proportions of their income on health care.
• Outpatient consultations in public/state facilities required about 82% of total average
expenditure on drugs. In the private sector it was about 50%.
A third set of data is from a document (12) that explores the measurement of a health line.
One component of this is the assessment of the economic burden of the health loss to the
household. It takes account not only of health expenditure but loss of healthy days due to
illness. The poor are more likely to suffer frequent illness than the rich because of the general
deprivations of the poor. Measurements were based on 10 case studies. Among the ten;
• the average loss of income, and expenditure on illness together amounted to 10.8% of
income;
• expenditure on health alone was an average of 4.6% of income;
• The total loss ranged from 3.5% in one case to 60% of monthly income in another.
Another document - a report of a micro level study on Seasonality and Health (13) in five
locations examines the seasonal variation in ill health and includes a profile of expenditure on
health by households. The analysis shows that in the sample the heaviest financial burden is
borne by the poorest households in the five communities. Another feature was that in farming
communities ill health - and therefore expenditure for health care- escalated during cultivation
because of the nature of the tasks involved and the wet weather conditions. This was also the
time at which incomes were lowest since the households had long disposed of their harvests
and experienced financial strain until the next harvest is due. Costs of health care would deter
such households from using health care when it was most needed.
The highest expenditure of 60% was incurred on western drugs that patients were compelled
to purchase from a private pharmacy owing to shortages in the State health institutions. The
next highest proportion of 25% was on transport, which was considerably more costly for
rural patients who accessed provincial or national health institutions. The three rural locations
spent 22%, 31 % and 35% on transport to health facilities. The fees paid for private services
were only 11%. The report further states that only 2% of the expenditure were on Ayurveda
treatment, which was utilised more by the rural poor. (13).
The fourth and last data set has been derived from case studies of low income households that
were experiencing illnesses of varying types among some of the household members
(summaries in Table A in Appendix A). The interviews provided information on income and
expenditure and cost of illness to the household. However, since the quantitative data could
not be sufficiently checked and verified and corrected for inconsistencies relative expenditure
could not be used as a useful single indicator of the burden of illness. This indicator has
therefore been used sparingly. It was found that the descriptive account of the financial
situation in each household provided some very useful descriptors of the poverty trap that was
a consequence of illness. The ensuing section therefore captures these situations vividly
providing images of the process of impoverishment in some cases and a fall into destitution in
others. The process will continue in the unforeseeable future that seems very bleak indeed with
little hope of recovery.
As an exploratory study the cases were purposively selected to cover both long-term chronic
illness and recurrent common ailments. In the latter type colds and fevers that were earlier
treated with home remedies are now increasingly complicated with viral infections. Medical
advice generally is that immediate consultation with a doctor is essential to rule out serious
infections. This necessitates at least one visit to a western medical doctor per child, which is
becoming more and more burdensome to poor families in which children are more likely to
suffer from such illness than children from non-poor families. Given the nature of the study
and the time spent the information set out here is more descriptive than analytical.
The illnesses are classified under the two types of (a) recurrent ad hoc and (b) long-term
chronic illnesses. The second category belongs to the newly emerging diseases, but even the
earlier category of common colds and fevers is now manifesting new symptoms with viral
infections that demand a different regime of treatment and care from that which prevailed
earlier. The case studies present the processes of further impoverishment and the
consequences for poverty within the different situations of illness in already poor households.
Consequences for Poverty
In the cases where young children had frequent viral infections, colds and fevers and
respiratory infections as a consequence, the expenses were generally unforeseen, depending on
the incidence of illness and the number of visits to a doctor, taxi fare, the cost of drugs from
private sources and the cost of diagnostic tests. The burden was found to be heavy on already
strained incomes and heavier still when a single parent (mother) was the main provider. She
had to nurse as well as take the child(ren) for treatment and in addition forgo the wages she
earns to maintain her household. It also strained the finances of her siblings and parents on
whose support she depended for some part of her daily needs. In the case in question the old
father of the widowed female had perforce to increase his workload to earn the extra support
needed for the daughter’s family. Nevertheless his family finances were stretched to
unaffordable limits. There was therefore a spiralling of poverty that could occur in clusters of
poor households that attempted to be supportive in times of illness.
When children’s’ illnesses were combined with a chronic ailment of an elderly parent in the
same household, the burden was compounded. In this case recurrent expenditure on the
parents illness was approximately 13% of the usual household income. These were for drugs,
transport to the hospital and special food. In the same household, that depleted income had to
meet the costs of recurrent illnesses of children that required consultations with western
doctors, drugs that had to be purchased from a private source and transport that together
amounted to about 15% of their monthly income in the past three months.
Households that depended on garden produce for part of their income had invariably lost out
in competing activities related to illness. One household lost 32% of income with crop not
harvested in time. Indebtedness quite often exacerbated their deprivation and poverty in such
households. Debts that amounted to 15% of household income were not uncommon.
Interestingly considerable sums were being spent even by poor households on charms and
rituals that were believed to be beneficial to the patient. This was the practice even in the cases
of children’s colds and fevers and respiratory infections when the cycle of viral infections and
related illnesses appeared to weaken their faith in medication alone and to demand that solace
be sought through appeasing the deities. An impressionistic assessment would place the
proportion of poor households affected by recurring common illnesses at around 90%.
In the category of chronic long- term illnesses, the diseases ranged from a child’s chronic
asthma and serious allergic condition, to paralysis, diabetes with complications, kidney
ailments and cancer. These are ailments that are not uncommon currently among the poor.
While the duration of the cancer was only four months the other ailments covered a period
ranging from 4 years to 10 years. Throughout this period each of the households was seen to
be going through a process of impoverishment and they present clear manifestations of being
enmeshed in a poverty trap from which they see no means of escape. There were no safety
nets or assistance for recovery. Here, Younus’s grameen bank in Bangladesh comes to mind as
a safety net that provided for just such contingencies.
In cases where the main provider was struck down, his loss of income was compounded by the
adverse effects of the illness on the family members. It had affected the education of young
children that was perceived by the poor as the only conduit for progress in life. It deprived
older children of jobs/job opportunities, and in most cases where nursing care was required
prevented the spouse seeking income-earning avenues that would relieve the burden of the
household. Intergenerational poverty therefore prevented recovery by the next generation as
well. The situation in these households diminished the opportunities for marriage of young
members, while even their food consumption was reduced to a bare minimum.
Those who had some assets began gradually selling, even furniture and equipment and
mortgaging land. Loss of cultivable land and loss of crops when the household was
incapacitated contributed to enhancing the poverty conditions in the household.
Young families that depended on self-employment that they had carried on with reasonable
success, had lost their investment in the enterprise, their savings and their enterprise at one go
when the chief occupant became ill. One family so struck down at the beginning of their family
life 10 years ago, had to abandon plans to build a family or a future home together.
Others who had set themselves up as independent self-reliant family units became beholden to
their siblings even for their shelter and food, or else their deprivation as a result of illness
shifted a part of the burden on already poor households of their parents and siblings.
The treatment for illnesses was mainly accessed through the western allopathic system.
Although there is no charge for health care in State institutions all of the cases cited were
purchasing a regular monthly quota of drugs from private sources. In the case of all the
chronic ailments in the case studies, missing even one dose of a drug could have serious
consequences for the condition of the patient, be it diabetes, kidney ailment or hypertensive
conditions. It is likely that given the privations they experienced many instances of drugs being
unaffordable would have had grave consequences for the illness. State hospitals often ran short
of, at times the more expensive drugs and at such times prescriptions were given for purchases
outside. When free drugs were available it was through a clinic that the patient had to attend
and this involved taxi hire and an accompanying person who had to spend a precious morning
at the hospital with income forgone for that day. This compelled most patients to skip the
clinic and buy drugs from the pharmacy.
Households spent as much as 12-15% of a meagre income to purchase drugs each month.
Significantly even greater proportions were spent on charms and religious rituals on behalf of
patients. This for chronic ailments such as diabetes and paralysis shows a serious gap in
information regarding new and emerging diseases and the long care regimes they require. This
expenditure was surprisingly incurred even for recurrent children’s illnesses such as viral
infections.
Resorting to charms and ritual has traditionally been a feature of the health seeking behaviour
of all sections of society but the poor who can ill afford such expenses are equally ridden with
a sense of guilt if the spiritual powers are not invoked on behalf of their loved one.
One exceptional case of a family that is slowly but surely progressing towards destitution in
attempting to “treat” through drugs, alternative medicine charms and rituals a Mongoloid
disabled child of six years is an example of the grave failure on the part of the system and the
media to provide information in general and in more personalised counselling of parents of
children with incurable birth defects. On the other hand would parents and family accept a
doctor’s verdict as final and unalterable in the environment where recourse to higher spiritual
sources and faith in those has been an inherent part of the social psyche of our people. Who
will dare devalue such faith and belief - if not always in its healing power, in its capacity to
provide comfort and solace to a despairing household.
These vignettes provide unassailable evidence of the vicious cycle of illness and destitution
that appears to leave entire households impaired for more than a generation, where the death
of the patient, however loved and wanted would invariably be a relief to both the patient and
the household. But that relief has been far away for most of the cases cited here.
Section
5
Conclusion
The MPT as it unfolds in this exploratory study, spans both poverty and health concerns in
countries in the Asian region. As a specific type of poverty it appears to have its roots in the
consequences of economic reforms. Its links go further however, to the conditions that
determined the specific nature of the economic reforms in each country which in turn was
determined by the macro policies that had fashioned economic and social conditions in the
country over the years.
It was shown that in the Asian region the MPT had a niche in macro policy, in health policy
and the social traditions of each country. It was made clear from the three country studies that
showed widely differing situations in which the MPT could occur, that interventions related to
MPT will first need to identify and pin down the determining factors of MPT. The design of
interventions will depend on those factors. The possibility of a MPT arising in situations where
medical care is provided free of charge by the State is in itself a signal that many hidden
factors combine to produce unexpected outcomes for the poor. All countries in the Asian
region would benefit from examining health expenditure by households more intensively and
within a poverty framework that would highlight the spiralling poverty that is a consequence
of out-of-pocket medical expenditure.
It appears imperative that even for countries such as Sri Lanka and China that have a serious
concern for the poverty that prevails in their societies and that have poverty alleviating
programmes for the poor and the indigent, the phenomenon highlighted here of a near invisible
type of poverty that traps households under unavoidable circumstances merits further study.
These are circumstances that need to be foreseen and safety nets put in place for recovery or
better still for prevention of the conditions of poverty arising from illness. There is a need to
recognise the medical poverty trap as we see it occurring in the Sri Lanka cases, as evidence
of an inherent defect in the system of social welfare which prides itself on the efficacy of the
twin interventions of welfare - free health and free education for all. It is time to look closely
at the way free health care works on the ground for the poor in plunging households and
family into an irrecoverable state of destitution.
In the case of countries such as China that have opted for user fees for health and have
attempted to alleviate its adverse consequences for the poor through several types of safety
nets, the need for continuous monitoring of the working of those mechanisms is indicated. The
inefficiencies of targeting are all too clearly known and documented for any kind of
complacency about the poor being adequately covered by special programmes. There is
undoubtedly a need for poor-oriented programmes. The fault appears to lie in the absence of a
systematic surveillance system that ensures they perform for the poor. There is a need for
space for further inquiry, to seek answers to questions that relate to assessment of the MPT. Is
a “relative expenditure” approach adequate to cover the complexity of the manifestation of
MPT? How important is it to follow a process of impoverishment to understand its
ramifications? What measurements can capture the spiralling poverty that characterises MPT?
The Sri Lanka experience of 1971 demonstrates the unexpected impact of user fees on
utilisation. The possible exclusion of the genuinely ill poor at the time was not investigated.
Considering the escalating costs of medical care, arising also from changing disease patterns.
National Health Systems will be increasingly strained for finances. Given the health poverty
links how can the National Health System be organised to address the many and varied
outcomes it is required to ensure.
Arriving at the correct mix of strategies is a constant challenge and requires intensive studies
to understand the reality at the ground level. In the emerging health scenario the importance of
a new PHC system cannot be over-emphasised. This area posed the most intractable dilemma
for developing countries. The type of PHC services such, as diagnostic and monitoring tests
for cancer for instance are costly and unaffordable for the poor. The consequences of not
monitoring are higher costs for curative care once the disease is advanced and of course the
inevitable cycle of poverty that sets in for poor households and the impoverishment of the non
poor.
Health education has been one of the most productive interventions in improvement of health
status, through prevention and management of communicable diseases. This is not as easily
delivered nor are the effects as clearly demonstrable in the case of non-communicable diseases.
Precautions and instructions for prevention should be do-able and affordable. If not the
inequities will be heightened between the poor and the non-poor.
Further research needs to be designed carefully to capture as many of the variables that can
identify typologies of poor households and the differences in their situations as they attempt to
cope with high medical expenditure. Such studies would make it possible to gauge the
“proneness” of types of households and prevent their fall into a medical poverty trap.
Appendix: A
Table 1: Key Economic, Demographic and Health Indicators for Selected Asian Countries
Indicator
Year
India
Unit
China
Vietnam
34
13
26
22
10
6
17
GNP Per Capita
1993
USS.
310
670
220
100(92)
190
600
2110
620(95)
240(95)
People in Absolute Poverty
1990
%
31
17
52
40
22
19
19(97)
29(97)
One Year-Olds Immunized
1992
%
90
92
69
74
73
88
86
98
88
63
71
18
24
71
79
79
2395
2755
2019
2598
1957
2275
2443
2708
2438
64(92)
74
93
59
Daily per Capita Calorie Supply
1992
Kcal
Population With Access to Health Services
1993
%
50
80
30
10
90
30
1.9
2.7
5.9
7.4
4.7
5.2
8.2
1980
1.6
2.5
4.3
5.3
3.9
4.9
4.1
1975
2.4
2.0
5.4
6.6
5.9
6.1
3.7
50
82
36
82
26
89
93
1980
36(77)
62(78)
26(77)
66
19
85(79)
86
1970
34
57
23
60(60)
14
78
79
1992
89
109
83
100
24
1970
137
140
121
157
Maternal Mortality Rate (per 100,000 live births)
1988
550
650
600
Human Development Index (HDI Value)
1995
0.451
0.371
Life Expectancy at Birth
1995
61.6
2
1993
1992
% Tot. Exp.
%
Years
1992
Annual Population Growth Rate
1960-1992
%
1992-2000
Fertility Rate
>
----------
Source:
*
Thailand
8(90)
Infant Mortality Rate (per 1000 births)
' -4
Sri Lanka
30(90)
Adult Literacy Rate
)
Nepal
%
Central Government Expenditure on Health*
-no
Myanmar
1991
1980
W
Bangladesh
Low Birth Weight Babies
1987
CO \
W -
Indonesia
1992
1970
%
2
0.4
80
88.6
26
29 (91)
39 (91)
53
73
69
850
180
180
130
400
0.481
0.351
0.716
0.838
0.644 (92)
...(92)
56.9
58.9
55.9
72.5
69.5
69.2
66.4
59.7
52.2
56.9
52.7
71.2
68.7
70.5
63.4
2.2
2.7
2.2
2.5
1.8
2.4
1.9
2.2
1.8
2.4
2.1
2.4
1.2
1.1
1.2
2.0
4.0
4.8
4.3
5.6
2.5
2.3
2.3
4.0
5.8
7.0
5.9
6.4
4.3
5.5
5.8
The figures given are not fully comparable as they are from different sources, and different periods of reference due to non-availability.
World Dev. Report 1995 & 1996 - World Bank
Economic & Social Survey of Asia & Pacific 1996 - UN
Human Dev. Report 1994 & 1995 - UN
Social Indicators of Development 1994 - World Bank
World Tables 1980 & 1994 - World Bank
Enhancement of Social Security for the poor - Marga Institute
.. Not Available
Table 2: Data on Health Expenditure Derived from Consumer Finance Surveys:
I
Percentage of Expenditure on Food Per Spending Unit Per Month in Low & Upper Income Groups, Out of All Current Expenditure.
II
Percentage of Expenditure on Medical Care Per Person Per Month Out Of Total Per Capita Health & Non Health Expenditure for Low & Upper Income Groups.
Items
1.
11.
111.
a.
Average Expenditure on Food Per Spending Unit (%)
Medical Expenditure as a % of Total Expenditure Per Capita,
Per Month____________________________________________
Per Capita Medical Expenditure by Type (%)________________
Ayurvedic (Fee, Test, Hospital Charges)
Low Income Group
SL Rs.* T SL Rs.
SL Rs.* ~~
QclOOO
0<4500
0<1500
1981/82
1986/87
1996/97
_______68
_______ 70
_ 71__
1.5
1.8
2.2
0.9
22
b.
Ayurvedic Drugs
17
6.4
c.
Consultation Fees (Western)
12
7.2
b.
Drugs and Medical Test
70
78
e.
Hospital Charges
f.
Charms etc.
g-
Premia Paid on Insurance on Health
h.
Spectacles, Dental Care & Other
i.
Homeopathy
Total Health Expenditure Per Capita (SL Rs.)
72
Upper Income Group
Over SL
Over SL Rs.* Over SL Rs.
Rs.* 2000
3000
12000
1981/82
1986/87
1996/97
________41
_______ 57
_________ 34
2.2
3.4
2.6
11
3
3
80
11
9.4
78
54
3.2
4
0.7
1.2
19.2
8.5
7.4
0.3
0.33
6.2
0.1
0.1
2
1.4
0.5
0.6
0.3
6.6
0.1
2.91
5.33
12.5
12.32
53.39
105.16
165
247.18
838.62
572
1552.54
3990.85
Total Health & Non Health Expenditure Per Capita Per Month
(SL Rs.)
*
Income Group
Sources:
Consumer Finance Survey 1981/82, 1986/87, 1996/97 Central Bank - Sri Lanka
Note:
The figures from CFS. 1981/82 & 1986/87 were derived for Income Group, for 1996/97 die Figures are in respect of Income Deciles.
Table 3- Summaries of Case Studies - Sri Lanka
Case
no:
Type / description
of illness
Description of
family
House hold
economy
Description of
the poverty trap
Medical
expenditure
Losses due
to sickness
Total financial
losses
( Monthly average of past 3
months)
(Per month )
(Per month including
medical expenditure)
♦ For the past 3 months
the mother has spent her
entire
earnings on the sick
children.
* Total financial
loss - 103% of total
monthly income.
♦ The entire household
suffered privations in food.
♦ Her father worked extra
hours each day to meet the
extra expenses on her
children’s illness.
♦ Childrens’ school
attendance has dropped.
♦ There were earlier
occasions when she
pawned her jewellery to
spend on childrens’
illnesses.
♦ In past 3 months the
mother lost
approximately 1/2
months wages by
staying home to look
after the sick i.e.
Rs. 2000 (p.m.)
♦ Loss of produce from
garden because they
could not harvest on
time Rs. 2000.
* Total Financial
loss - 68% of total
monthly income.
♦The family had to borrow
money Rs 1500 for daily
expenses.
♦Construction work on
house was stopped.
♦ Unable to save.
Common recurrent
illness
A.
.2.
Colds \ fever and a
chronic bronchial
condition in 3 young
children.
(1 ) Fever\cough ,
tonsils & respiratory
infections in children.
(2 ) Acute rheumatic
condition in elderly
patient for the past 5
years.
10 members a widow, 3 young
children living with
her parents & siblings.
8 members - family
with 3 children,
elderly mother &
siblings.
♦ Mother - casual
worker earned
Total: Rs 3,000
(per month )
♦ Food and
accommodation is
provided by her
parents.
♦ Husband in
pennanent job earns Rs
4000
♦ wife (garment
factory) earns
Rs 4000
♦ Additional occasional
from garden produce
Rs 2000
Total: Rs 8,000
( per month )
(Rs)
♦ Transport & hospital
charges
- 500
♦Drugs
- 2000
♦Ayurveda - 300
♦Vitamins - 300
Total Rs 3,100
(Rs)
Elderly patient:
Transport & drugs 1050
(13% of their usual
income).
Children
♦Private consultation &
drugs
666
♦Vitamins 100
766
Lump sum
♦Charms & religious
rituals, etc. 6000
2000 ( average per
month)
Total Rs 2,766
% of reduced income
46%
Contd.
Case
no:
Type / description
of illness
Description of
family
House hold
economy
Chronic long term
illness
.3.
Allergy / wheeze in 9
year old child for 8
years.
Description of
the poverty trap
Medical
expenditure
Losses due
to sickness
Total financial
losses
( Monthly average of past
3 months)
( Per month)
( Per month including
medical expenditure)
* Income forgone by
parents’ not being able
to work was an average
of Rs 2500 (p.m)
* Total financial
loss - 39% of total
monthly income.
♦Child has virtually
dropped out of education
* No savings.
♦Mother can not improve
her enterprise
♦Their earnings depends
on continuous work . They
lost wages for
non - working days.
♦Income forgone by
main provider Rs 7000
(income reduced by
32%)
* Expected income from
land was lost.
♦ Cultivation
neglected.
* Total financial
loss - 84% of total
monthly income.
♦ Expenses exceeds
income ,the gap being
met with assistance from
relatives & friends.
♦Loss of future earnings from cultivation.
♦ Fear that they may be
compelled to sell their
main asset- 2 acres of
land
.♦ Fallen into poverty
from a non-poor status.
Rs
A family of 3 .
♦ Father - casual
worker earns
Rs 5000 (p.m.)
♦ Mother - self
employed earns
Rs 8000
Total : Rs 13,000 (
per month)
♦ Private consultation
& drugs
- 2000
♦Special food - 500
Lump sum ( 3 months)
Religious rituals -100
33 ( average per month
)
Total Rs 2,600
% of reduped income
24 %.
.4.
Main provider has
Cancer which was
detected 4 months ago.
A family of 4 with 3
earners.
♦ Total earned by 3
persons
Rs 15,000 (per
month average income
)
♦ Had commenced
cultivation on 2 acre
land.
(Rs)
♦Hospital charges 200
♦Tests 2000
♦Drugs
1500
* Ayurveda 500
♦Religious rituals 1200
Total Rs 5,600
% of reduced income
70 %.
Contd.
Case
no:
.5.
Type / description of
illness
Main provider paralysed
after a stroke for 5 years.
Description of
family
A family of 3 with a
school going
daughter.
House hold
economy
*Wife earns
Rs 150 a day from
casual work. Their
usual income was
around
Medical
expenditure
Losses due
to sickness
Total financial
losses
( Monthly average of past
3 months)
( Per month )
(Per month including
medical expenditure)
♦ Loss of income of
the main provider
Rs 3500.
•Intermittent loss of
wife’s earnings
approx.: Rs.450 (p.m)
Usual income was
therefore
Rs 2550 - 3000.
♦ Total financial
loss - 80% of total
monthly income.
(Rs)
♦ Hospital & tests 275
* Religious rituals &
charms 1000
Total Rs 1,275
Total : Rs 3,000
(per month )
% of reduced income
50 %.
Description of
the poverty trap
* Loss of investment
of total savings Rs
25,000 on catering
equipment.
* Family members are
not in a position to
assist.
♦Loss of income of
Rs 3500 (per month)
from main provider.
♦Family depends on
casual work of wife,
♦they spent about
Rs 300 on drugs per
month because the
wife can not go to the
state hospital clinic.
* Daughter’s
education is
interrupted.
♦Debt of Rs 5000
which can not be
repaid.
♦Wife’s regular
attendance affected her wages reduced
because she has to
nurse the patient.
* House in a state of
disrepair.
Case
no:
.6.
.7.
Type / description
of illness
Main provider
suffers from a
progressive kidney
ailment for the past
10 years.
(Progressively
worsening
condition).
Wife has diabetes
with other
complications for the
past 4 years.
Description of
family
Family of 2 , living
with sister who
provides food &
accommodation
Family of 4 with 2
school going
daughters.
House hold
economy
* Husband earned
from fishing but
gradually reduced
income & currently
can not work.
* The sister provides
food &
accommodation for
them.
* Wife earns
Rs 2,000 p.m. from
selling of breakfast
food.
* Husbands income
from fishing
Rs. 15,000 p.m was
sufficient for daily
expenses
* Eldest daughter
earned Rs 2000 from
casual work.
Total: Rs 17,000
(per month )
Medical
expenditure
Losses due
to sickness
Total financial
losses
( Monthly average of past
3 months )
( Per month )
( Per month including
medical expenditure)
* Loss of earnings of
husband Rs 4000
replaced by wife’s
new earnings of
Rs2000
* Total financial
loss - 170% of total
monthly income.
♦ Shifted from rented house to sisters’
residence.
♦ Totally dependent on sisters’
charity.
♦Wife’s earnings totally
spent on his medical expenses .
♦ No savings.
♦ In debt for about Rs 2000.
♦ Reduction of
income by 10% as
the husband has to
care for the wife.
♦ Eldest daughter
had to give up her
casual work
Rs 2000 (p.m.)
* Reduction of income
approximately 20%.
Total financial
loss - 42% of total
monthly income.
♦ Reduction of husband’s income by
intermittent loss of work to care for the
sick wife.
♦ Eldest daughter gave up her job.
♦ Second child’s education is
interrupted
♦ House hold furniture was sold from
time to time.
♦ Their only stable asset - a plot of
land has been mortgaged.
♦Money was borrowed from money
lenders.
They have to continue in this manner
as long as the patient lives.
(Rs)
♦ Hospital charges 500
♦Private drugs
- 600
Special food
- 300
Total Rs 1,400
Description of
the poverty trap
% of reduced income
70 %.
(Rs)
* Drugs
- 360
Lump sum (3 months)
♦Religious rituals
10,000
3300
(average per month)
Total Rs 3,660
% of reduced income
27%
Total Rs 3,500
Case
no:
.8.
Type / description
of illness
Main provider has
been paralysed for
the past 7 years.
Description of
family
A family of 5 . With
3 children (2 school
going.)
House hold
economy
♦ Wife & daughter
doing domestic work
- Rs2000
♦Daughter’s income
of (garment factory)
Rs 2250 (1 1/2 m:
)
Total:
Rs.4,250 (p m.)
Medical
expenditure
Losses due
to sickness
Total financial
losses
( Monthly average of past
3 months)
( Per month )
(Per month including
medical expenditure)
(Rs)
♦Hospital charges 416
♦Drugs & Transport 500
916
Total Lump sum
(last 3 month )
♦ Religious rituals 7000
♦ Patients income of
Rs 5000 replaced
with Wife’s income
as a domestic helper
Rs2000.
Total
Description of
the poverty trap
*Total financial
loss - 110% of
total monthly
income.
♦Loss of patients’ income.
♦Loss of wife’s income.
♦ Loss of part income of the eldest
daughter due to absenteeism.
♦ Younger daughter’s
education is interrupted.
♦ Daughters marriage prospects affected.
♦ Unable to complete construction of
their house.
♦All past savings exhausted
♦No savings or security for the future.
Poverty alleviation prog: of gov
emmet has given them Rs 500 (per
month) but not sufficient even for
medical expenses.
*Total financialloss - 46% of
total monthly
income.
Hospital charges,
private drugs , special food, Ayurveda
treatment & charms have amounted to
Rs 350,00 in past 6 years. .
Rs7,000
2300 (Ave :per:
month)
Total Rs 3,216
% of reduced income
76%.
Special case
.9.
Mongoloid / disabled
child.
Family with 4 .
Their
only son aged 6
1/2 is the patient.
♦ Father employed
(casual job) &
mother in home
based - sewing.
(Rs)
♦Private drugs 370
♦ Special food 240
♦ Ayurveda
600
* Loss of husbands
income ( from loss of
days of work) &
wife’s income .
Total Rs 1,210
Total : Rs 8,000
(pm.)
Note:
Medical expenditure was obtained in respect of past 3 months
& a monthly average shown in the chart.
Total Rs 2,500
% of reduced income
22 %.
♦ Wife’s home - based
income earned activity is often
interrupted as she has to care for the
child.
♦Daughter’s education is disrupted.
♦ Could not construct their house .
♦ Sold the motor - bike for child’s
illness.
♦ They do not accept that the child is
permanently disabled.
Appendix B - References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
Health Care In Asia A Comparative Study Of Cost And Financing - World Bank Regional And
Sectoral Studies-1992
Gunatilleke, Godfrey Monograph On Poverty And Health: Regional Issues
Creese A., Kutzin J. ; Forum On Health Sector Reform, Discussion Paper No. 2,1995
Gunatilleke, Godfrey; Equity in Health- The Case of Sri Lanka- WHO June 1998
Feng X, Tang S,Bloom G, Segall M, Gu Y; Cooperative Medical Schemes In Contemporary
Rural China- Social Science & Medicine- October 1995
Prof. Dahlgren, Goran, Dr.Lieu Huy Duong; Health Care Financing and Access to Health Care
Services in China- Some Facts and Experiences.
W.C.Hsiao; The Chinese Health Care System: Lessons For Other Nations
Pham Manh Hung, Truong Viet Dzung Dahlgren ;Efficient Equity- Oriented Health Sector
Reforms: A Vietnamese Perspective On Some Key Issues
Ranan-Eliya Ravindra, De Mel Nishan; Resource Mobilization For The Health Sector In Sri
Lanka - Harvard University
Gunatilleke, Godfrey ,Managing The Health Transition In Sri Lanka- WHO
Samarasinghe D.Daya, Akin S. John; Report Of The Health Strategy And Financing Study
Gunatilleke, Godfrey; The Health Line- A Measurement To Ascertain The Population Below A
Minimum Level Of Health
Gunatilleke, Godfrey, Perera P.D.A. ,Femando Joel, Fernando Eardley; Seasonality And
Health
Gunatilleke, Godfrey, Myrtle Perera, Rajapakse A.L ; Poverty And Its Effects On Health
Alleviation Of Povertythrough Technical Cooperation Among Developing Countries,-WHO
1995
Gunatilleke, Godfrey et al; Trends In Poverty And The Living Conditions Of The Poor In Sri
Lanka- SIDA 1994
Report On Consumer Finance And Socio Economic Survey 1981/82 Sri Lanka Part 1, Part 2 Central Bank of Sri Lanka
Report On Consumer Finance And Socio Economic Survey 1986/87 Sri Lanka Part 1, Part 2 Central Bank of Sri Lanka
Gunatilleke, Godfrey; The Presidential Task Force Proposals For Reforms In The Health
Sector-WHO 1997
United Nations Human Development Report 1994,1998,1999
United Nations-Economic And Social Survey Of Asia And Pacific 1996
Wei, Ying; Pilot Field Study On The Health Care Security System (PFSHSS) In Poor Rural
Area In China
Weiping, Li; Study On The Cooperative Catastrophic Medical Expense Insurance In Chinese
Rural Area
World Bank- Social Indicators Of Development 1994
World Bank- World Development Report 1995,1996
World Bank- World Tables, 1980 & 1994
Annual Health Bulletins - Ministry of Health Sri Lanka
(Dr. Godfrey Gunatilleke’s input from several informal discussions on the subject is
gratefully acknowledged)
Appendix - C
Outline For A Future Study on MPT:
The broad outline that is set out is for a set of case studies that can not only provide data on
the impact of medical expenditure on poor households but also assists in conceptualising
issues related to out of pocket medical expenses.
The design of the study is based on the premise that while medical expenditure would in
general have an over arching effect on increasing the financial constraints in poor households,
different typologies of poor households would respond differently to financial burdens. The
study would make distinctions between the varied typologies of poverty and examine the
impact of medical expenditures severally in these. The outcome would be a set of risk models
for different household poverty models.
It will entail intensive studies of shifts in income sources, seasonality, conditionality and flow
of income in addition to its quantum. Poverty will be related to other conditions of living and
availability of common amenities. Other variables that would directly impinge on ill health will
be considered.
Another element of poverty causing expenditure is to be the lack of knowledge and access to
knowledge that leads to inappropriate and wasteful spending.
The study needs to differentiate between two categories of chronic and recurrent morbidity.
Location of residence will figure significantly as a variable that determines access to services
and the quality of services as well as the choices that are available.
The duration of the study should be at least one year, since the process and the cycle of
change has to be studied. In designing the method of research and selection of cases micro
level research that has been carried out by the Marga Institute can contribute substantially by
providing data, back ground information, village, community and household profiles from a
number of studies some of which have dealt specifically with issues related to health care.
A total of 20 case studies would be sufficient to construct risk models that would then
determine the nature of interventions that would most effectively address the problem of
compensating the poor for the financial burden of medical care.
{I acknowledge with thanks the contribution made by Dr. Nimal Gunatilleke with whom I had
discussions through E-mail on the type of research that would best contribute to knowledge of the
subject of medical care and its effect on poverty}
GENDER IMPACTS OF HEALTH REFORMS THE CURRENT STATE OF POLICY AND
IMPLEMENTATION
By
Hilary Standing
Institute of Development Studies,
University of Sussex, UK
Paper for ALAMES Meeting, Havana, Cuba, 3-7th July 2000
GENDER IMPACTS OF HEALTH REFORMS - THE CURRENT STATE OF
POLICY AND IMPLEMENTATION
In 1997,1 wrote a paper on gender and health sector reforms (HSR). It raised a series
of questions about the gender implications of health reforms mainly in low income
countries. It was largely speculative as there was little hard information at that time.
I revisited the policy questions in a further review in 1999 (see Standing 1997, 1999)
In this paper, I will try to update the picture, taking into account particularly changes
in the language and concepts of health reform and moves towards a more
intersectoral view of health. I will focus on the following issues:
•
•
•
•
•
•
•
The importance of contextualising health reforms and associated impacts, such as
the different economic, political, demographic and epidemiological drivers in
different countries
The change in language from “first generation” supply side reforms to “second
generation” emphasis on greater demand side and anti-poverty interventions
The continuing problem of lack of data
Marketisation in the health sector and the resulting pluralism of provision
Decentralisation and accountability
“Systems” versus advocacy approaches - the example of reproductive health and
health sector reform
Policy issues in relation to gender inequalities in health
1. Contextualising health reforms and gender impacts
Health reforms have been taking place globally at an accelerating pace over the last
decade. This has been in response to a range of different drivers. In countries which
have undergone structural adjustment, the main drivers have been constraints on
government expenditure and donor conditionalities. In transition economies, health
systems are being reconstructed as a response to economic liberalisation and the need
to move away from command and control management models. There has been an
ideological dimension to some reforms, manifest in a rethinking of the role of
governments in the delivery of health care, and moves towards decentralisation/
devolution of management to lower levels. In many countries these have combined
with important population based changes. These include:
• Ageing populations coupled with changing health needs and different demands for
health entitlements;
• Changes in the epidemiological profile, for instance as a consequence of high rates
of HIV infection;
• Greater access to specialised knowledge and a provider “market.”
This has meant that health reforms have taken different paths in different contexts.
We should not therefore look for one story in relation to gender impacts. Nor are the
gender concerns posed by epidemiological trends going to be the same everywhere.
Let us briefly contrast specific trends in two regions:
In the countries of the former Soviet Union, mortality trends show a serious decline in
life expectancy. Whilst life expectancy has declined over the last 30 years, it has
declined particularly dramatically for men. It is now estimated to be 71 for women
and only 59 for men (UNFPA, 1998). The causes are still debated, but high levels of
alcohol related illness associated with psycho-social factors such as lack of
employment have been implicated (Eberstadt 1999). The gender implications of this
encompass issues such as family breakdown, loss of economic and psychological
support to households and tackling prevailing cultures of masculinity.
In sub-Saharan Africa, 27.1 million of the 39.2 million people estimated to be infected
with HIV/AIDS are in sub-Saharan Africa. Of these, 55% are women. Sub-Saharan
Africa not only has the bulk of HIV/AIDS global burden. It is also the one area where
the female infection rate is higher than that of males (UNAIDS: 1999). The
consequences of this for the gender division of labour and the management of
household reproductive burdens are profound and as yet inadequately documented.
Social stigma and blaming of women for the crisis are noted in a number of countries,
as is lack of control by women over the means to protect themselves. Health sector
planning, particularly for supportive care and for empowering women and girls to
gain control in sexual relationships, will have to address these issues.
2. Health reforms - from first to second generation
The language of health sector reform, as expressed by international agencies and
governments, has changed over the decade from the early 1990s. The “first
generation” of reforms was overwhelmingly supply side driven and focused on and
within the health sector. In the “second generation,” many of those basic elements
remain firmly in place, but the emphasis has shifted more to the demand side and the
language has broadened towards anti-poverty interventions and intersectoral
approaches to health.
First generation — major elements ofsupply side reforms:
• Improving health sector management systems
• Public sector reform
• Cost effectiveness of interventions
• Reform of financing mechanisms, cost containment
• Decentralisation
•Working with the private sector
In many developing countries, this agenda has been heavily donor driven and linked
to economic adjustment and liberalisation. But a similar menu has been pursued in
most reforming countries, including some northern ones. This first generation has
been distinguished by a number of serious shortcomings. The focus was purely on
system level change (such as reforming the functioning of Ministries of Health) with
no associated monitoring of outcomes for health and impact on service delivery. For
example, donors have generally hailed the health reforms in Zambia as a success. Yet
the period over which they took place saw a decline in a number of key health
indicators such as IMR (Simms et.al.). Change was seen as a set of technical and
managerial activities, rather than as a political process to be negotiated between
stakeholders. There was no consciousness of the need to consider gender or other
significant indicators of disadvantage in planning, implementing or monitoring
reforms. As a result, it continues to be extremely difficult to get a comprehensive
view of the gender impact of health reforms.
Second generation — towards sector wide and anti-poverty interventions?
•
•
•
Partnerships with key stakeholders, e.g. SWAps, CBOs/govemments
Focus on community/user needs (e.g. through Participatory Poverty Assessments)
Health as part of the poverty agenda (e.g. social insurance, microcredit)
More recently, international agency language and approaches have shifted quite
significantly. Partly, this has been due to a tacit acknowledgement of the relative
failure of reforms in a number of countries, particularly in sub-Saharan Africa, to
deliver any obvious improvements on the demand side (while recognising that this
cannot all be laid at the door of the health sector). However, in other countries too,
widening gaps between rich and poor in health status and health care access (e.g.
China and other Asian countries) have raised serious questions about the content and
direction of reforms.
This is beginning to result in some broader thinking about reform. Both governments
and donors are stressing the importance of partnerships between key stakeholders,
although the concept of partnership remains underdeveloped. These are taking
various forms: the so-called public-private partnerships between governments and
different elements of the private sector, and partnerships between governments and a
variety of civil society groups such as NGOs and other community based
organisations which have (or are being encouraged to develop) a capability in
planning, service delivery or monitoring. In countries with significant donor support
to the health sector, there has been a move away from donor specific project funding
to sector wide approaches (SWAps) negotiated between governments and the “pool”
of aid donors (Evers 1999).
Some recognition of the limitations of supply driven reforms has resulted in greater
attention to the needs and concerns of users. This has taken a number of forms. The
World Bank’s recent conversion to participatory methods has resulted in participatory
poverty assessments (PPAs) being institutionalised in their country poverty strategy
reports. Health concerns figure in a number of these. Some countries have instituted
mechanisms for consulting users on issues such as priority setting (see e.g. IPPR
2000). In others, coalitions of civil society stakeholders such as consumer groups,
trade unions etc. have developed advocacy strategies to enable them to voice needs
and interests (Loewenson 1999, Cornwall, Lucas and Pasteur 2000)
There has been a renewed concern internationally with the intersections between
poverty and health. The anti-poverty agenda has itself broadened to take in a more
dynamic and social understanding of poverty and its determinants. The conceptual
shift towards definitions of poverty which focus on risk, vulnerability and exclusion
(see WDR 2000) has brought health risks more centrally into policy debate. That ill
health can be both a cause and a consequence of poverty has been clear for a very
long time. However, it has taken time to get back onto the international agenda. This
concern is currently most influential in health financing strategies. Safety net
mechanisms to protect the poor against catastrophic illness and to provide subsidies or
or
basic insurance for health care are high on the agenda, as is the linking of micro-credit
to health care. These strategies have many - as yet largely unexplored - gender
implications.
3. Marketisation and provider pluralism
In many countries an increasingly unregulated health care market has emerged in
which a wide range of providers, including public sector agencies, private sector
players, NGOs and traditional healers are practising. These practitioners may or may
not be qualified or competent. Health reforms have generally failed to acknowledge
this diversity, proceeding instead as if a comprehensive public sector health system
were in place (Bloom and Standing 1998). Yet, statistics from a number of countries
show the increasing share of health expenditure which is taking place outside of the
public sector, including among poor people.
This raises many important issues on the demand side. How are users (male and
female) responding to the unregulated market? What kinds of services are being used
and why? We know that women in particular make a number of trade offs in deciding
which practitioners to consult. These include distance, the opportunity costs of their
time, the perceived quality of the service (and particularly the attitude of the provider)
and the costs of treatment. The transactions costs of the unregulated market are very
high for the poor. Reforms have not addressed how to enable poor users, particularly
the non-literate, to make more informed choices in an increasingly marketised
environment.
One key to this is information. People now receive health information from a wide
range of sources (eg, pharmacies, drug pedlars, the media). How can better
information dissemination systems be created within the health sector, especially with
regard to the information needs of poor people? As Sen (1999) points out, formal
education and literacy are not the only information needs which women have. There is
a need to provide information both to users and front line health staff and improve the
access of poor women and men to good basic information on services and drugs.
Again, health reforms have barely addressed this. Where are the examples of
innovative information dissemination, such as the use of low cost software for service
providers and on drug suitability and dosage for users?
On the supply side, there is an urgent need to develop ways of monitoring and
regulating services in pluralistic environments. At national/subnational level, what
bodies are appropriate to take on these functions? What mechanisms and procedures
can be developed to do this? How can they be made more accountable and woman
friendly? Global markets in health commodities also require better regulation. Many
countries are struggling with the problem of how to introduce and maintain a rational
drug pricing and consumption strategy in the face of powerful transnational cartels.
These take advantage of WTO-GATT rules and weak or non-existent national
controls to sell branded drugs at high prices, or dump unnecessary or banned drugs on
the open market. Pineda-Ofreneo and Estrada-Claudio (n d.) note that one commonly
used branded contraceptive retails at $2.77 in the Philippines, $1.97 in Taiwan and 90
cents in Indonesia.
4. Decentralisation and accountability
Different forms of decentralisation are posing considerable challenges to the
effectiveness of service delivery and the accountability of providers. We still know
little about the gender impacts of decentralisation. However, Aitken (1998) has
explored the question from the point of view of impacts on reproductive health
services. Noting that commitments by governments to the 1994 Cairo agenda already
imply significant changes to the way services are delivered, Aitken looks at how this
agenda fares under decentralisation. He finds that national policies often fail to get
implemented locally, either because budgets are not allocated at local level, or
because implementing agents disapprove of a policy and do not cany it out. This was
particularly the case on “minority” services such as management of incomplete
abortions, or sexual health services for adolescents. Conservatism and judgemental
attitudes can be powerfully expressed and legitimated where implementation depends
on local will.
Other problems include too hasty a process of change and a resultant incapacity to
manage the complexities of reproductive health services, especially where the unit of
implementation is too small; and mismanagement of human resources through
changes in terms and conditions and lack of training.
In the context of decentralisation, the following questions need to be considered in
order to create an environment more responsive to gender issues:
• Which actors can do what to create more responsive services in increasingly
decentralised systems?
• What is the relationship between decentralisation and responsiveness to users’
needs? What services are being provided?
• What if any examples are there of pressure for service improvement from below?
What strengthens/impedes this happening?
• How is human resources management and training addressing the changing
agenda in areas such as reproductive health in the context of public sector reform
and decentralisation?
• Incentives for and motivation of health workers: how can the switch be made from
target based approaches to quality based approaches?
• Empowering advocacy groups to hold providers and governments to account what do they need to know, what expertise do they require, and how can they
acquire it?
5. “Systems” and advocacy approaches - gender, reproductive health and health
sector reforms
Reproductive health (RH) provides a good test of how a more comprehensive and
gender friendly approach to service organisation and delivery fares in the context of
broader health reforms. The RH approach came out of the Cairo International
Conference on Population and Development (ICPD) in 1994. It inaugurated a hard
fought for, comprehensive concept which went beyond family planning to encompass
the lifecycle health needs of women and men in relation to all aspects of human
reproduction. Two aspects of the development of the RH approach are particularly
relevant to health reform.
First, the RH approach owes its existence and vitality largely to the women’s
movement and particularly to women’s health advocacy groups in both south and
north which have found ways of exploiting political spaces to get progressive policies
onto the international agenda. This has entailed working through relevant
international conventions (e.g. the Convention on the Elimination of all forms of
Discrimination against Women - CEDAW) and pushing through resolutions in
international fora (e.g. the Beijing Women’s Conference). It has enabled women’s
health groups and NGOs to use the language and (albeit less successfully) the legal
apparatus of human rights in advocating for policies. For instance, an issue such as
maternal mortality rates in poor countries has been reframed as a rights violation.
The rights discourse has both strengths and limitations. It has proved extremely
powerful as an international advocacy tool. It has drawn attention to the shocking
neglect of even basic health entitlements for many poor people. It opens up the
possibility for greater voice among those lacking such entitlements (via demands from
below ’ as opposed to need identified and defined from “above”). Its limitations
stem from the enormous difficulty of any kind of enforcement. Conventions and
resolutions ratified by countries depend on self-regulation and on interpretation
according to local circumstances. Nor have rich countries exhibited the commitment
to providing resources to poor countries which would make compliance more feasible.
Second, RH remains largely an approach - a vision of what should be achieved
(Myntti and Cottingham 1999). It has not proved easy to translate into practice.
There is a considerable gap between on the ground service delivery issues with which
RH is associated, and system level approaches to health sector reform. Thus, there is
a very large number of micro level initiatives in the RH field. There is a lot of good
experience, particularly among NGOs, of delivering quality services, especially to
female clients. But there is very limited experience of or capacity for scaling up.
Experience of RH in the comprehensive sense is very limited and for the moment
mostly a feature of demonstration projects. An international seminar in Addis Ababa
in 1996 noted that despite the paradigm shift since Cairo, most programmes lacked
ability to deliver comprehensive services. This is changing only slowly. In
particular, management and organisational capability needs to improve, and service
provision needs broadening, e.g. through treatment of RTIs, programmes on men’s
health (International Council... 1997).
There are several reasons for the limited progress in realising the ICPD objectives.
1. RH has been framed within a different language from HSR (i.e. managerial/
technical concerns v. human rights/women’s empowerment concerns). Whilst the
women s health movement has made very good use of the tools of international
advocacy, there has not been sufficient dialogue with the national and
international agencies driving HSR.
2.
Similarly, RH has been focused on service delivery issues, to the neglect of
broader systems level thinking. As Fonn et.al. (1998) point out, a malfunctioning
system cannot work for a woman in labour when it does not work for a man with
typhoid either. RH advocates have only recently begun to tackle HSR on a
systems terrain, with a number of operational research initiatives now coming on
stream.
3. Systems issues are quite hard to address. One problem is where RH lies in system
terms. Largely based in vertical programmes (e.g. family planning, MCH), its
components are often split between different ministries/sectors, producing
stakeholder conflicts between different line ministries. RH tends to be a visionary
approach, not a technical area or sector with a budget attached. Another problem
is the dominant focus in health reforms on the role of the public sector and the
neglect of provider pluralism. The private sector plays a very significant role in
RH service delivery, often in areas where women find it most difficult to access
services, such as providing abortions. A systems approach to RH needs to take a
broader view of the concept of a system than much of the current HSR thinking.
4. Progress continues to be restricted by problems of data availability. According to
ARROW, few data on RH are available disaggregated by age, urban-rural,
class/income, religion/culture, ethnicity. Country studies of programme
implementation suggest little serious attention by policy makers. There are
currently no agreed core indicators for monitoring a rights based approach to
women’s health as advocated by the Beijing Platform for Action. ARROW
suggests that wider indicators of women’s health status should be developed, such
as the degree of gender based violence. They also point to the need to develop a
monitoring framework for financial indicators which can both differentiate
spending on specific services, and monitor spending on comprehensive services.
On the positive side, some countries have incorporated RH objectives into their
development plans. For instance, in Ghana, a World Bank credit for a Health Sector
Support Program put family planning, obstetrics and STD services into the work
programme as part of the priority service interventions. It remains to be seen whether
this is enough to guarantee implementation.
Finally, participants at the Addis Ababa Seminar (ibid.) suggested the following key
challenges to implementing an RH approach at a system level:
•
•
•
•
Skills development for advocacy, leadership and planning, management and
implementation
Developing supportive management systems: planning, management information
systems, human resources management, logistics
Sorting out financing and interdepartmental issues
Translating development plans into action
6. Policy issues in relation to gender inequalities in health
In this section, I will focus on some major policy and implementation issues at three
levels: subnational, national and supranational. Cross cutting each of these is a set of
common concerns which are particularly relevant to gender inequalities in health.
These are concerns about participation, voice and govemance/accountability (Bangser
6.1 Subnational strategies
Political and bureaucratic decentralisation has proceeded at an increasing pace in
many countries. Decentralisation raises many complex* issues about the relationship
between gender and health (Standing 1997, and see Aitken above op.cit ). It does not
lend itself to a straightforward assumption that decentralisation is good for increasing
gender and health equity. However, as there has been a number of very innovative
programmes on women’s health focused at municipal level (e.g. PAISM), it is worth
raising the question as to what are the circumstances which favour greater attention to
gender issues in health.
Bangser (op.cit.) raises some interesting questions about this stemming from her
discussion of the ReproSalud project in Peru. This widely praised project, which runs
in four regions of the country, had begun in the late 1970s with a group of women
activists concerned primarily with promoting self-esteem and political leadership
among poor women. It expanded, with donor funding, in the 1990s and is based on
the premise that good reproductive health for women is linked to having control over
social and economic conditions. It is thus an “integrated” development project with a
strong focus on community involvement and participation by local voices.
At the same time, Bangser notes that attempts to achieve larger scale, national level
multisectoral approaches to health status have not met with much success. Perhaps
the often desired but rarely achieved goal of a multisectoral approach is most realistic
at subnational levels? In which case, what kinds of agencies and arrangements are
most likely to achieve more integrated aims? What is the optimum size/reach of some
programmes?
6.2 Nationalfinancing strategies
Financing systems have gender implications. Different systems can have very
important consequences for women’s capacity to access services. For example, cost
recovery through point of service charges has been associated with a decline in the
use of maternal health services, particularly hospital based ones (Kutzin 1995). User
charges in this sense have been the most visible manifestation of many health reform
programmes and have attracted the most political attention.
However, the link between point of service charging and utilisation remains a
complex one. Schneider and Gilson (1999) note that the South African government’s
removal of user charges for MCH services did not result in any increase in take up of
maternity services apart from a modest increase in the number of antenatal visits.
They suggest that a wider set of measures is needed, including significant
improvements in the quality of care provided. Similarly, it could be argued that user
charges need to be seen as part of a broader question of how services are funded
nationally and how financing strategies as whole affect women and men differently.
Increasingly, in poor and even middle income countries, we have seen the same
segmentation of populations emerging in terms of how health care needs are met.
Main modalitiesforfunding individual/household health care needs:
1 Insurance schemes for formal sector workers
2. Basic health insurance or community financing for the moderately poor
3. Micro-credit and funds for catastrophic illness for the very poor
This of course raises larger equity issues which are beyond the scope of this review.
In the context of broader gender equity issues, it may also be noted that women will
be disproportionately represented in the third category, given the prevailing
distribution of poverty. For current purposes, however, I will focus on potential
gender impacts within each of these categories.
There have been a number of innovative ways in which supranational advocacy and
action are having an effect. For example, women’s groups have been involved in the
WHO led negotiations over the Framework for Tobacco Control (FCTC). This was a
direct result of putting tobacco and women’s health on the Beijing Plus 5 agenda.
An even more innovative supranational initiative is the “Women on Waves” project.
This is a planned sea-going women’s health clinic which will sail entirely in
international waters and will thereby be protected by international law, but will target
countries where abortion is illegal and provide termination and care services
(Guardian 2000).
These new opportunities thrown up by globalisation and the internationalisation of
advocacy face us with new challenges on governance and accountability. Who is
entitled to speak or frame action at this level and who are they accountable to? Which
voices get heard the loudest and how can the least advantaged gain some
representation? The multilateral agencies are being called rightly into account for
their actions. But similar issues of accountability and voice will need airing by
advocacy groups as well.
ACKNOWLEDGEMENTS
I would particularly like to thank Elaine Baume, research assistant to the EDS Health
and Social Change Programme, for her excellent searching skills. This paper was
prepared with financial assistance from DFID’s Latin America regional desk. My
thanks to Dr Jenny Amery, Health Adviser for the region, for facilitating this.
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The Heritage Foundation
Evers, B. (1999) Economic liberalisation - Health sector reform - Gender and
reproductive health. Working document for discussion at RHAG Meeting, October
Fonn, S. et.al. (1998) Reproductive health services in South Africa: from rhetoric to
implementation. Reproductive Health Matters vol. 6, no.l 1: 22-32
Institute for Public Policy Research, Website
http./Zwww.piporguk/reference.htm
International Council on Management of Population Programmes (1997) Managing
Quality Reproductive Health Programmes: after Cairo and Beyond. Report of an
International seminar, Addis Ababa, December 1996
Kutzin, J. (1995) Experience with organizational and financing reform of the health
sector. Current concerns SHS Paper no. S (SHS/CC/94.3) Geneva: World Health
Organization
Myntti, C. & Cottingham, J. (1999) Gender and Reproductive Health'
Conceptualising the Relationship. Unpublished Draft.
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health insurance and women’s coverage
http .7/www. paho.org/english/ags/agsmsd 18.htm
PATH (1999) Linking women’s health and credit in India: Program experience and
future action. Conference Report January 22nd, India International Centre New
Delhi, India
and Estrada"claudio (n d ) Globalisation and its impact on women'
the Philippines experience. Paper prepared for the Seminar on Globalisation
PhftipphT an<1 SCX Trafficking' 25'26 February, Boalan, Zambaanga City,
Schnejder, H. & Gilson, L. (1999) The impact of free maternal health care in south
tea Safe Motherhood Initiatives: Critical Issues. Reproductive Health
Matters/Blackwell Science
Sen, G. (1999) Engendering poverty alleviation: challenges and opportunities
Development and Change 30 685-692
Simms, C. et.al.
Stand>n& H (1997) Gender and equity in health sector reform programmes: a review
Health Policy and Planning vol 12, no. 1 1-18
Standing H (1999) Frameworks for understanding gender inequalities and health
sector reform: an analysis and review of policy issues. Harvard Center for
Poulation and Development Studies Working Paper no 99.06
UNAIDS (1999) AIDS epidemic update, December
UNFPA, 1998, ‘The state of the world's population - The new generations’
World Bank (forthcoming) World Development Report 2000 (draft) Washington
DC: The World Bank
PANAMERICAN HEALTH ORGANIZATION
WOMEN, HEALTH AND DEVELOPMENT PROGRAM
GENDER EQUITY AND HEALTH SECTOR REFORM POLICIES
Analytical Guide for Presentation to Subcommittee on
Women Health and Development
INTRODUCTION
In keeping with the decision of the 17th Subcommittee on Women, Health, and Development (1997) this
gmde provides an outline for the analysis that each Member of the Subcommittee will produce and present
during the biennial session of the Subcommittee 18th meeting, 8-9 February, 1999.
At its last meeting, the Subcommittee selected “Development of Public Policies that Influence.Womem
Health, and Development’’ as the general theme for the IS* session and agreed that members would
p cipate in the preparation of documents. The definition of the specific topic within this theme was left to
the Secretanat, which chose the topic “Gender Equity and Health Sector Reform”, based on the following:
The evidence that certain health and social security policies have an impact on gender equity.
Ongoing health sector reform, combined with globalization and the modernization of the State in the
majonty of the countries of the Region.
The absence of gender equity considerations in these reforms.
outlines 1116 gender issues Solved in the main components of health sector reform
^e^On. 7116
section Provides a short overview of the basic concepts of gender equity in
HbK, and the following four sections include gender-related considerations and questions that address each
oi tiie principal components of health sector reforms:
uqd
Decentralization and promotion of social participation
Reorganization of the sendees, including models of care, and definition of basic packages of
interventions and services.
Restructuring of human resources management systems.
Changes in financing, including private sector participation.
Based on the HSR experience in its country, each member of the Subcommittee will analyze those
components of the reform process that are relevant for Ute country and for which information is available.
The analysis should relate to broader national policies governing health and State reform processes.
Each Subcommittee Member will share its experience during a 15-minute presentation on 9 Februaiy. The
P1^65^3^0115
not distributed before the meeting, but documents could be available during the
1. BASIC CONCEPTS OF GENDER EQUITY IN HEALTH
Gender Perspective in Health
Approaching health from a gender perspective means recognizing that:
□
Beyond the biological or sex difierences between men and women, there are socially constructed
gender distinctions that affect women and men’s health and their position within the health system.
Gender values and norms translate into different roles, risks, needs, access to resources, and power to
make health decisions both in the private and the public spheres.
□ Gender—together with class and ethnicity—is a key determinant of health opportunities, both at the
individual and family level, and at the macro level of resource allocation within the system.
In the gender division of roles, women's work is consistently undervalued'. In the formal health sector,
women are concentrated in occupations associated with lower pay, prestige, and decision-making
power, in the informal sector women’s work is free, and not factored into national accounts.
□
□ Women have the cultural responsibility ofhealth care provision in the home. As such they are the main
multipliers of health and human development but also are the most affected by changes in the
provision of services in the formal health sector.
□ Gender inequalities are articulated and reinforced by other power inequalities. The elimination of
gender inequalities thus demands the involvement of different social sectors, as well as the democratic
participation of civil society, particularly organized women’s groups.
Gender Equity in Health
The principle of equity in health is rooted in the recognition of health as a human right Within this context
of human rights, gender equity and women’s rights in health have been highlighted and ratified at the
International Conferences of Vienna, Cairo, Copenhagen, and Beijing, as well as in the Summit of the
Americas.
The notion of gender equity in health applies to:
□ Health status: The elimination of unnecessary, unjust, and avoidable differences in the opportunity to
enjoy health and in the probability of becoming ill, incapacitated, or dying from preventable causes.
□
Access to and utilization of health services: Men and women receiving care according to their needs.
□ Health care financing: Women and men contributing according to their economic ability and women
not having to pay more than men because of their reproductive role and their longer life expectancy.
□ Participation in the production of health care: Balance in terms both of work (remunerated or
unremunerated) and decision-making power.
Why the Emphasis on Women?
Men and women occupy different positions with respect to the use and delivery of health care. The
emphasis on women, both as users and providers of care, is based on the following factors:
□ Women have a greater need for health services due, particularly, to their reproductive roles and their
longer life span.
□ Women are disproportionately represented among the poor. Women tend to have less access to
remunerated work and health resources, including health insurance and long-term social security.
□ Women are in a position of disadvantage within the health system. They predominate in the levels
of lowest pay, prestige, and power within the formal health sector; and they perform the informal work
of health promotion and health care in their families and communities without remuneration.
2
1 Formal sector insurance schemes
Health insurance schemes for formal sector employees raise a number of issues from
the point of view of gender impact:
• Do they cover maternity care?
• Do they impose additional payment burdens or other penalties on women?
• What happens to non/unemployed members?
For example, Chile’s ISAPRES private health insurance scheme require workers to
the health insurance premium, compulsory for salaried workers and voluntary for
independent workers, to a private insurance entity in order to obtain the health
services and benefits stipulated in its respective health plan. Competition in the sector
has led some ISAPREs to launch initiatives that, in principle, facilitate coverage in
areas that are especially sensitive for women, e.g. marital health plans, which are
shared premiums for spouses, making it possible to distribute maternity costs more
equitably.
However, ISAPRES work on standard commercial risk sharing principles. Applying
the risk factor, the price of the coverage increases as a function of sex, age and the
number of dependants. Women therefore have to pay an increased premium to
compensate for their maternity costs, or accept less coverage. Such schemes, while
providing a relatively high level of security to formal sector workers as a whole, raise
important questions about the wider principle of risk sharing and who bears the costs
of human reproduction.
More generally, insurance schemes of themselves are unlikely to compensate for the
impact of the often different relationships which women and men have to the labour
market. Women’s employment patterns and histories may be more diverse and
fragmented, leading to breaks in coverage. Differentiation within the labour market
may lead to greater concentrations of women in low paid segments or to more casual
contracts. Action is needed at a societal level to reduce the consequences of these
kinds of inequities.
2. Basic health insurance or community financing schemes for the moderately poor.
Experience of these is patchy. There has been some progress in community financing
schemes under the Bamako Initiative in Africa, particularly through revolving drug
funds. In China, attempts are underway to rehabilitate the Community Medical
Schemes which provided cover for farming households. In most such schemes,
coverage is necessarily selective. They might pay a proportion of costs, costs of a
certain level of treatment only, or costs of certain conditions. A key gender issue is
whether they cover RH conditions and of what kind.
There are very few examples of insurance schemes geared to informal sector workers,
which is where the majority of employed women are located. A notable one is that of
the Self-Employed Women’s Association (SEWA) in Ahmedabad, western India.
SEW A set up an integrated work security scheme in 1992, one element of which is
medical insurance (PATH 1999). This scheme is particularly worthy of attention as it
operates partly through commercial insurance companies, thus defying the view that
informal sector workers cannot be reached through such means. Whilst coverage is
quite limited (to hospital care only), experience indicates that it is very much valued
by women members. One important side effect has been stronger demands by women
for better treatment at facilities, thus increasing women’s voice and developing
greater accountability on the provider side.
3. Micro-credit and funds for catastrophic illness for the very poor
Micro-credit is rapidly becoming one of the favoured instruments of poverty
alleviation programmes, particularly for increasing incomes of the poor and for
empowering women. More recently, there have been attempts to link it to health
objectives, such as by incorporating pre-pay MCH schemes, medical treatment plans
and health related micro-enterprises. Evidence so far is fairly anecdotal, and
evaluations are based largely on client perceptions. A recent seminar reviewing the
Indian experience of micro-credit programmes linked to health objectives highlighted
the following positive gender aspects:
• Self-help groups help women to develop leadership skills which often lead to
health needs becoming a priority
• Men’s involvement in programmes can be a positive force for better
communication on health and family planning issues
• Credit programmes are a good place to introduce programmes for preventing
violence against women.
Cautions have also been expressed. Most schemes tend to be small scale and run by
NGOs. They can run up against lack of co-operation from official structures and
health providers. A recent report from India also notes a trend for poor women to take
loans for covering the costs of hospitalisation (Ramachandran 2000). An unusually
high rate of referral for hysterectomies in private sector facilities was found.
Attempts to provide catastrophic illness cover for the very poor are very limited so
far. China is now experimenting with such a scheme in pilot rural counties. At issue
in gender terms is less what gets covered than whether women in rural households are
able to claim the same entitlements to treatment as men.
Finally, there is now increasing interest in women’s budgets as a tool for monitoring
public expenditure. For instance, in the Philippines, aWomen’s Budget Statement has
been introduced on resources for women-specific projects. This sets an allocation of
at least 20% of the national budget to social programmes and services. Experience of
these monitoring tools needs synthesising and evaluating. Creative thinking is also
needed on how to monitor and influence non-government expenditure in areas like
health.
6,3 Supranational strategies
The success of the women’s health movement in working at a supranational level to
get women’s health onto national and international policy agendas has already been
noted. Whilst processes of globalisation have arguably resulted in increasing loss of
national sovereignty, they have also opened up greater opportunities for this kind of
advocacy and action. The concept of health as a global public good - a shared global
resource to be protected - is gaining some credence in international debate (Kaul et.al.
1999). It is important that gender becomes part of this debate. Women’s health
advocates have stressed women’s health as a right. Arguing the case for maternal
health or freedom from gender violence as a global public good allows another entry
point for advocacy.
□ Women are the principal health care givers in the family and are therefore the most affected by the
ill health of others in the household. Thus, for example, a child illness tends to affect mothers more
than other adult family members.
□ Because they are the principal managers of family’s health, women are key to effective and
sustainable health development, and are the link to intergenerational human development
Gender Equity and Health Sector Reform
From a gender perspective, the two most fundamental questions regarding HSR are the following:
Does HSR contribute to reduce or exacerbate the existing gender inequities in health, health
care, and decision making within the health system?
How does HSR affect women’s right to health —particularly women’s reproductive rights?
In the following sections, gender equity considerations are addressed in relation to each of the above
mentioned reform components1. The key issues are presented, followed by some questions. Please answer
these questions within the context of the ongoing HSR in your country and using available information,
such as sex-disaggregated statistics on mortality, morbidity, health needs, health care coverage and
utilization, socio-economic vulnerability, human resources, and social participation. Incorporate also
quantitative/qualitative information on decentralization, basic care packages, health care financing,
priorities and targeting.
Note that the distinction between reform components is only analytical, since in reality, there are importan
areas of overlapping between components. Therefore, some issues and questions will appear in more than
one component.
i
The main elements of the guide that follows have been borrowed and adapted from the work of Hilary
Standing, Gender and Equity in Health Sector Reform Programmes: A Review. Health Policy and
Planning; 12(1): 1-18, 1997.
3
2. DECENTRALIZATION AND PROMOTION OF SOCIAL PARTICIPATION
Examining gender equity within the context of decentralization
1. The decentralization of health resource management and the allocation of resources may result in an
unequal inter-regional distribution that may adversely affect the most vulnerable populations. To justly
target the distribution of resources, socio-economic vulnerability measures are required. These measures
could incorporate specific gender indicators, such as the proportion of women heads of household.
2. Decentralization may result in the transfer of power from the central to the regional or local elites, in
detriment to intra-regional equity. In cases where decentralization signifies competition for resources
between different types of elites, it is important to support the participation of women since they have been
traditionally excluded from power structures. It is important to underscore that while women provide the
community support system, community leaders are predominantly men who are not necessarily commited
to gender equity in the allocation of resources.
3. Decentralization may translate into a transfer of the financial burden of health care to local communities
and their institutions (both public and private), adversely affecting poverty alleviation. Cost reduction
strategies may have been linked to the use of decentralization as a tool for increasing community
participation in health services delivery. Under this situation home care increases, with women shouldering
an increased burden of providing care.
4. Recent interest in community participation within HSR has focused on efficiency and sustainability in
the financing and administration of health care. Very little attention has been paid to internal community
processes and to the central issue of how and when decentralized systems improve access by vulnerable
groups or marginalize them even further.
Questions about the gender equity implications of decentralization of health care
Please answer the following questions in your presentation, using examples and data to illustrate your
statements:___________________________________________________________________
1. Is decentralization of the health sector taking place in your country? If so, how are decisions
made on resource distribution between regions?
2.
At the local level, whc participates in the decisions about resource allocation? How is the
community or civil sector involved in making these decisions?
3.
What efforts are made to include groups that have traditionally been underrepresented, such as
indigenous groups and women?
4.
How are women and women’s interests represented in community power structures? Do women,
or their organizations participate in setting priorities? In planning programs? In their
implementation? In their evaluation?
5.
How can the participation of women in decision-making be promoted without increasing their
workload?
6.
Has decentralization included a transfer for providing care from the institutional to the home
setting (for sick household members, the elderly, and physically and mentally disabled people)?
What effect does this additional burden have on users and caregivers? Do any measures or
research exist regarding the effectiveness and sustainability of home care?
7. What support resources exist for providing health care in the home? What support structures
are being put into place for women (or men) as health care providers in the home?
4
3.
REORGANIZATION OF SERVICES: DEFINING MODELS OF CARE AND
BASIC CARE PACKAGES
This component generally includes organizational restructuring to improve human and financial resource
management, and the definition of priorities and cost-effective interventions. Important equity concerns in
defining priorities relate to the following basic issues: What criteria are used to determine health needs
within the wider population? What types of needs are being addressed and which needs are considered
priority? What criteria are used to assess cost-effectivenes? Human resource policies also raise issues
which are discussed in section IV.
Questions on the reorganization of services from a gender perspective:
Please answer the following questions for your presentation. Illustrate your discussion with results and data
available in your country.
1.
To what extent do the design of care models and integrated packages of services take into
account the needs of groups with special requirements, and the specific health care needs of
women throughout their life cycle (Le., from childhood to maturity)?
2.
How were these needs determined? By what means? By whom?
3.
How were priorities identified? Who participated in the negotiations? Did government agencies
in charge of the promotion of women participate? Organized women’s groups?
4.
Do the models and basic packages include health promotion, disease prevention, curative and
rehabilitation services?
5.
Do these models and packages include detection, care and referral services for women who
experience domestic violence?
6.
Do these models and packages consider the impact of gender power inequalities on women’s (and
men’s) health and on women’s ability to exercise their sexual and reproductive rights?
7.
Do reproductive health components exclusively target women, or do they incorporate
interventions for men?
8.
How was cost-effectiveness of priority interventions determined? What actors intervened in the
process?
9.
Are there mechanisms in place to monitor the effects of the new models and packages on the
health needs satisfaction of population and specific groups (including women)? Is civil society
involved in monitoring? Does it have access to information?
10. What would be the response if amid a general improvement of health systems operations and
health status indicators, equity deteriorated to the detriment of certain groups? Are there
remedial measures in place for such a situation? Who would arbitrate/decide?
11. Has there been any evaluation of how cutbacks in certain services may result in increases of the
time women spend caring for family members who are not healthy?
5
4. RESTRUCTURING HUMAN RESOURCES MANAGEMENT
This component includes cutbacks in personnel, changes in the contracting, payment, grading and
performance evaluation systems, and restructuring of post descriptions.
Reasons to examine gender equity in health sector work
1.
There is a strong correlation between gender and status in the health labor force. Senior positions are
predominantely held by men; women are disproportionately represented in the lower levels of
remuneration and decision making. It is likely that reductions in personnel will affect more adversely
the less powerful groups of employees, more of whom will be women.
2.
Evidence in many developing countries suggests that women are more likely to use certain health
services if the provider is female. Consequently, maintaining appropriate levels of female staffing may
be important to assure equity in access to services.
3.
While human resources policies tend to be gender neutral, in situations where there is a strong
imbalance in the sex composition of certain occupational categories, the effects of these policies may
not be neutral.
4.
As a result of the interaction between the formal and informal health care sectors, policies that have an
impact on staffing in the services simultaneously affect the magnitude of the informal burden of care
which falls predominantly on women.
Questions concerning gender considerations in the restructuring of human
resources management
Please answer the following questions for your presentation. Illustrate your discussion with results and data
available in your country'.
1.
What impact has health sector reform had on the gender composition of staffing at different
levels?
2.
How do specific health sector reforms affect those sectors dominated by women?
3.
Are reforms likely to affect female employees differently from male employees of comparable
status? (e.g.. regarding incentives policies)
4.
What effects have human resource policies had on relations between predominantly “male” and
“female” health service professions?
5.
Has the reduction in human resources been devolved onto unremunerated “community”
workers (frequently women) and/or onto home care provided by women?
6
6. BROADENING HEALTH FINANCING OPTIONS INCLUDING PRIVATE
SECTOR PARTICIPATION
There is a dearth of reliable information on the impacts of the different forms of health financing on the
population. The level of disaggregation of categories such as “the poor” is clearly insufficient for policy
making. There is a need for conceptually comparable disaggregated data, that permits identification of the
most affected groups, and measure and monitor the effects of different types of health care financing. Sex,
age, socioeconomic status, and geographical location are important inequity markers. Additionally, there
are other categories of people who are particularly vulnerable to cost recovery measures. For example,
female widows, elderly men with diminished family ties, the disabled, and orphaned children and
adolescents.
Gender equity issues to consider in health care financing
Cost recovery measures may affect women differently due to their greater need for services, their more
restricted access to income, and their role as main health carers for their children:
1. The majority of women are either outside of the labor market, and if employed, receive lower salaries
than men.
2. Women are disproportionately represented in part-time jobs and informal sector occupations that are
usually not covered by social security and health insurance benefits
3. Women have a greater need for services than men, particularly because of their role in reproduction:
a) Women of reproductive ages frequently have to pay higher health insurance premiums due to their
potential for pregnancy;
b) women in reproductive ages often have to pay a considerably higher proportion of their income in
out-of-pocket expenditures for health, compared with men of the same ages;
c) because of their greater longevity, women bear the larger share of insurance exclusions associated
with chronic diseases
4. Women are culturally responsible for the health care of their children. Their responsibility is not
confined to the home, but it often means out-of-pocket expenditures for their children’s medical
attention. Currently, more than 30% of the households in the Region are headed by women.
5. The financing (public or private) of preventive and public health services has a special relevance to
women because beyond their own specific needs for preventive care, they absorb most of the
additional burden of care imposed, for example, by diarrheal infections in children.
Questions regarding the gender and health implications of different models of
financing of health services.
Please answer the following questions in your presentation. Illustrate your discussion with results and data
available in your country.
1.
Which health care financing methods have been adopted in your country as part of health sector
reforms?
2.
How are these methods affecting or are likely to affect access to services? Which groups of
people have been or could be affected the most and how? Within these groups, are women
affected differently than men?
3.
What measures have been taken to mitigate the adverse impact of cost recovery on low income
groups (for example, community financing, exemptions, and subsidies)? How do these different
strategies affect or are likely to affect access to services by gender?
4.
To what extent are health insurance regimes (public or private) linked to employment status?
Does service coverage depend on the level of remuneration from work? Do women dependants of
7
covered persons have access to the same services?
5.
What type of coverage is provided for dependent housewives, domestic workers, part-time
employees, and workers in the informal sector of the economy? (These are all occupational
categories dominated by women)
6.
What is the proportion of men/women covered by health insurance? What types of insurance?
7.
Has the government developed regulatory regimes to lay down standards of service provision for
the private sector? Are there regulations directed to improve equity or to offset existing or
potential inequities in service delivery? Do these regulations explicitly address women’s health
needs and gender inequities in access?
8.
Does privatization increase or decrease the probability that low income groups will be
adequately served? Does it increase or decrease the probability that women’s specific health
needs will be adequately covered?
9.
Do health insurance systems charge a higher premium to women due to their reproductive
health needs? Do they cover chronic diseases?
10. How are reproductive health services (for example, family planning, prenatal care, and maternity
care/leave) financed? Who pays for them? (for example: government, tax mechanisms, employers,
donors, other actors, or women themselves) What services are included in different types of health
insurance packages?
11. To what extent is the private sector providing prevention services and helping to meet public
health objectives?
Within the context of measuring impact and identifying affected groups, it is important to progress in the
measurement of the following elements:
The hidden and not-so-hidden costs of services: transportation, drugs, time spent in transportation to
the consultation or to purchase the drugs, time lost in waiting, opportunity costs for the time of women,
etc.
>-
Which family members are most likely to use health services? What types of services? (Distinguish
family members by sex, levels of care used, and whether care is provided by public-private-traditional
sectors.)
Do increases in health expenditures result in reduced spending for other needs? Wlrat categories of
expenditure are affected?
What proportion of men’s and women’s income is spent on out-of-pocket health expenditures? Do
these proportions change according to type of health care financing?
8
Partnership in Health and Poverty:
Towards a common agenda
World Health Organization, 12- 14 June 2000
Geneva, Switzerland
Summary Report
I. Introduction
The World Health Organization (WHO) in collaboration with the World Bank, the
UK Department for International Development and the European Commission, held a
major meeting - Partnership in Health and Poverty: Towards a common agenda
(12 -14 June 2000) - with key development partners. The 130 participants included
experts from civil society organizations and academic institutions worldwide, senior
government officials from developing countries, and health and development officials
from UN and bilateral agencies, the World Bank and regional development banks.
The main objectives of the meeting were:
•
To provide a forum for exchanging information on current thinking on health
in development and on current practice related to health and poverty reduction
•
To identify critical gaps and obstacles in knowledge for action
•
To encourage participants (as key development actors) to discuss strategies on
how to strengthen partnerships and other efforts to integrate health into
national and international development planning
•
To stimulate joint action on research, policies and actions
•
To build linkages to forthcoming UN events and other international meetings.
Each of the eight sessions of the 3-day meeting was structured so as take stock of
current thinking and activities; to identify obstacles, opportunities and critical gaps in
knowledge for action; and to identify ideas and recommendations to be carried
forward and to specify the responsible actors.
The first four sessions focused on analysis of health and poverty, covering:
1.
2.
3.
4.
Health as an asset: protecting and improving health as a core development
strategy.
"Voices of the Poor" - the lessons for health.
Ill -health and poverty - addressing the links.
Globalization and health consequences for the poor.
The remaining four sessions focused on actions to protect and improve the health of
the poor:
5.
6.
7.
8.
Implications for health systems.
Implications for development policies.
Implications for processes at country level.
Implications for development partners.
1
IL Main observations
A, Health in poverty reduction and development: a political process
Several presentations focused on the strong evidence demonstrating the centrality of
health to reducing poverty and other deprivations (such as gender-related
disadvantages) and to promoting overall social and economic development. But there
was broad disappointment and frustration amongst the participants that this mounting
evidence has still to lead to major changes in the mind-set and actions of both health
and other development actors. The health community is still not doing enough to
ensure that health is accorded high priority in development planning; nor do actors in
other sectors give sufficiently high priority to health. The net result is that health is
typically absent or of low priority on national poverty-reduction and development
agendas, and not as high as it could be on the international development agenda.
To redress this, health actors need to recognise and meet their responsibility to
advocate that health is a critically important means of reducing poverty and promoting
human development. Similarly, the development community as a whole needs to back
the case for both making greater investments in health and for protecting and
promoting health in every sector, whether it be macro-planning, industry, agriculture
or trade. There was strong agreement that these goals can be achieved only if health
actors engage in the politics of development at the national level; simultaneously,
international agencies, in particular WHO, must continue the push to place health at
the forefront of the international development agenda. Health actors need to recognise
that health - like all sectors - is embedded in politics. If health actors are to rise to the
challenge of being effective political players, they will need to move beyond the
narrow bio-medical paradigm, equip themselves with requisite advocacy skills and
tools, and participate vigorously in the politics of development.
Opportunities for gaining greater political prominence for health include such key
forums as the five-year review of the World Summit for Social Development, the
World Trade Organization negotiations, G8 meetings. World Bank and IMF meetings,
and country-level poverty-reduction and debt-relief processes. In many of them, the
voice of health has only recently begun to be heard.
Despite the criticism of the inadequate pace of change, overall there was agreement
that health was far higher on the international development agenda than at any recent
time, and that opportunities flowing from this must be seized. The participation of
such a broad range of development actors at this meeting was itself proof of this,
namely the high stature of health and the growing consensus within the international
development community that it must act to promote health.
B. Health of the poor: the needfor strong commitment and a broader approach
There was widespread recognition at the meeting that for poor people their bodies are
critically important assets - often their only asset — for sustaining their survival and
2
livelihood. Consequently, good health is of vital importance to them and ill-health a
calamity.
Promoting health for the poor requires raising access to affordable, appropriate,
quality health services as well as creating an enabling environment to protect their
health. Consequently, strategies to promote the health of the poor must take a rights
approach, factoring for disadvantages engendered by gender, social exclusion, locale
and other factors. They must also build on and strengthen poor people’s capacity,
skills and knowledge; assure them dignity and respect; and reinforce their connections
to political and social systems that promote their well-being. These are essential
elements for the poor to be able to ensure that informal and formal health systems
respond to their felt needs and are accountable to them.
There was also strong consensus about the need for greater participatory research with
the poor. Much more needs to be known about their circumstances, needs and views.
This knowledge is needed both to design health systems that are responsive to them
and to clearly understand what actions outside the health sector will positively
influence the broader determinants of their health.
On a different front, participants cautioned that strategies to promote the health of the
poor must build on past policies and efforts that have been effective in promoting
their health, such as Primary Health Care and the Health for All initiative. While
efforts to promote the health of the poor are urgently needed, they must take stock of
both the best practices and the cautionary lessons of the past.
They also emphasized the need to ensure that societies and their governments are
truly committed to the effort of improving the health of the poor. Otherwise, this
effort will remain an initiative led by development agencies and donor governments,
jeopardizing the chances of success.
III. Strategic Actions for ‘health for the poor, health and
development’
To realize the goals of promoting the health of the poor and making investments for
health a central part of the development agenda, the following key strategic actions
were recommended by the meeting, relating to health systems, development policies,
country-level processes, and development partners.
•
To make health systems more effective in addressing the needs of poor people
requires: establishing more affordable and equitable payment systems (with
pre-payment/insurance instead of user charges); ensuring that health-sector
actors respect the poor; developing mechanisms to meaningfully involve poor
people in analysis and decisions; implementing explicit strategies to tackle
causes of particular disadvantages or deprivation, such as gender, social
exclusion or geographical isolation.
•
Health data need to be disaggregated by income, age, sex and locality if we are
to build a clearer understanding of poverty and who and where the poor are.
3
This is especially important with data used in health planning and monitoring,
so that actions can be geared to the real and local causes and consequences of
poverty, and the impact of investments measured. This disaggregated data
must be part of a larger ’knowledge creation' effort to rapidly analyse,
document and disseminate what does and does not work for the poor. This
knowledge base will need to be informed by both quantitative and qualitative
studies, and by research that documents the expressed health needs of the
poor.
•
The health threats and disadvantages that are primarily responsible for
creating and perpetuating poverty need to be tackled urgently. These include
major infectious diseases, maternal illness and mortality, poor environmental
health, violence and accidents, and major emergent threats like tobacco and
other unhealthy consumer and food products. The particular health risks facing
a community need to be assessed at a local level rather than be set on the basis
of aggregated national or international data. These assessments must also
highlight the different needs and risks faced by men, women and children.
•
More effective resource mobilization is needed to multiply the financial and
human resources available for health systems. These resources can be secured
by strengthening the commitment of existing partners and by establishing
partnerships with new allies.
•
At the same time, the underlying determinants of health must be addressed and
made more pro-health. For significant and sustainable gains in health
outcomes, beyond action on the immediate manifestations of disease, action is
needed on the underlying determinants of health. For instance, there is little
point in building clinics if people cannot reach nor afford them, or are turned
away because of discrimination.
•
To bring health to the centre of poverty-reduction and development strategies
requires building public-private partnerships between governments, civil
society organizations, the private sector and international agencies at both the
country and international levels. These partnerships must link the health
community to other development actors. Within government, health ministries
must become equal partners of ministries of finance, planning and trade.
•
Action at the country level must be accompanied by action at the global level
to stimulate the development of global public goods in health and to ensure
that health is protected and promoted in the globalization process.
4
IV. Conclusions
The strong consensus of the participants was that this meeting was an important step
forward in developing a common agenda on promoting both the health of the poor and
the role of health in development. As the first meeting within the UN system on these
issues, it had laid the foundations for several essential elements: a common, holistic
knowledge base; a working-consensus on key actions and strategies; and a partnership
for action. To make further rapid and real progress in achieving this common agenda,
participants said that three things had to be ensured. First, that WHO - as the lead
health agency — and all other institutions present had to continue to place top priority
on these issues. Second, that all participants needed to sustain this partnership with
their firm individual and organizational commitment. Third, that they needed to
advocate within their own organizations for action on these fronts.
For other information or to provide comments, please contact Meeting Coordinator
Margareta Skold HSD/WHO Geneva E-mail: skoldm@who.int
5
Partnership in Health and Poverty: towards a common agenda
Executive Board Meeting Room
12-14 June 2000
World Health Organization, Geneva, Switzerland
Final List of Participants
Participants from Countries:
KADYRALIEVA, Ainura (Dr) Specialist on Monitoring and Evaluation, Ministry of Health,
Bishtek 72004, Kyrgyz Republic, Fax: (00 99 ) 6 312 66 06 57, Tel: (00 99) 6 312 66 05 81,
e-mail: abt_bish@infotel.kg
MORALES, Rolando (Dr) Adviser PAHO, La Paz, Bolivia, Fax: (00 59) 12 41 11 34, Tel: (00
59) 12 32 75 49, e-mail: rolando@caoba.entelnet.bo
NGUYEN HAI, Huu, (Dr) Director-General of Social Department, Ministry of Labour, Invalid
and Social Affairs, 12 Ngo Quyen St. Hoan Ken District, Hanoi, Vietnam, Fax: (00 84) 4
9344004, Tel: (00 84) 4 8247939, e-mail: vnhepr@netnam.org.vn
ROVERE, Mario (Dr) International Financial Coordinator, Unit, Ministry of Social Development
& Environment, Av. 9 de Julio, 1925, P13, 1552 Buenos Aires, Argentina, Fax: (00 54) 11 43
83 44 39, Tel: (00 54) 11 43 79 36 14, e-mail: mrovere@pccpwcom.ar
TCHETVERNINA, Tatyana (Dr) Head of the Centre for Labour Market Studies, Institute of
Economics Russian Academy of Sciences, 32 Nikhimovsky prospect Moscow, 11 72 18
Moscow, Russian Federation, Fax: (00 7) 95 3107001, Tel: (00 7) 95 1290188
e-mail: tchetver@yahoo.com
Bilateral agencies
Australia: TAPP, Charles (Mr) Deputy Director-General, AusAID, G.P.O. Box 887,Canberra,
ACT 2601, Australia. Fax: (00 61) 2 6206 4880, Tel: (00 61) 2 6206 4000.
France: BILGER, Catherine (Dr) Charge de Mission, Ministere de la Sante (Solidarite et
Emploi), Delegation des Affaires internationales, 8 av. de Segur, 75007 Paris, France, Fax: (00
33) 1 40 56 72 43, Tel: (00 33) 1 40 56 60 00, e-mail: catherine-bilger@sante.gouv.fr
France: VARET, Francoise (Dr) Chef de Division du developpement sanitaire et social,
Ministre des Affaires etrangers, 20 rue Monsieur, 75 007 Paris, France, Fax: (00 33) 1 53 69
37 19, Tel: (00 33) 1 53 69 31 87, e-mail: francoise.varet@diplomatic.fr
Denmark: SCHLEIMANN, Finn (Dr) Chief Technical Adviser, Technical Advisory Services,
Ministry of Foreign Affairs, Asiatisk Plads 2, DK-1448 Copenhagen, Denmark, Fax: (00 45) 33
92 07 90, Tel: (00 45) 33 92 13 82, e-mail: finsch@um.dk orfmn.s@inet.uni2.dk
Finland: LANKINEN, Kari (Dr) Consultant to the Ministry for Foreign Affairs, Department for
International Development Cooperation Unit for Sectoral Policy Advice, Katajanokanlaituri 3,
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P.O. Box 127, F-00161, Helsinki, Finland, Fax: (00 358) 9 825 1549, Tel: (00 358) 40 553
3422, e-mail: kari.lankinen@psrconsulting.com
Germany: KORTE, Rolf (Dr) Head of Department, Health, Education, Emergencies, Deutsche
Gesellschaft fur Technische Zusammenarbeit (GTZ) GmbH, Dag-Hammarskjbld-Weg 1-5, P.O.
Box 5180, 65726 Eschborn, Germany, Fax: (00 49) 6196 79 71 04, Tel: (00 49) 6196 79 13
06, e-mail: rolf.korte@gtz.de
Ireland: JOWETT Matthew (Mr) Representative Health Economist, c/o Department of Foreign
Affairs, 80 St Stephens Green, Dublin 2, Ireland, Fax: (00 44) 1 904 43 27 01, Tel: (00 44) 1
904 433 716, e-mail: mjl4@york.ac.uk
Italy: MISSONI, Eduardo. (Dr) Health Adviser/WHO Liaison Officer, Directorate General for
Development Cooperation, Ministry for Foreign Affairs, v. Salvatore Coutarini, 25, 00194 Rome,
Italy, Fax: (00 39) 06 324 0585, Tel: (00 39) 06 323 6900, e-mail: missoni@esteri.it
Japan: MAEDA, Miou (Ms) Deputy Director, Research and Programming Division, Economic
Cooperation Bureau, Ministry of Foreign Affairs, Japan, Fax: (00 81) 3 3593 8021,
Tel: (00 81) 3 3580 3311
Netherlands: STREEFLAND, Pieter (Professor) Senior Health Social Scientist, Royal Tropical
Institute, & Professor, University of Amsterdam, PC Box 95001, 1090 HA Amsterdam, The
Netherlands, Fax: (00 31) 20 5688444, Tel: (00 31) 20 525 2670
e-mail: streefland@pscw.uva.nl
Norway: OLSEN, Ingvar Theo, Consultant, Health Economics, Euggeniesgate 17, 0168 Oslo,
Norway, Fax: (00 47) 22 42 48 £3, Tel: (00 47)22 46 44 40
Sweden: PAULSSON, Goran (Dr) Senior Programme Office, Health Division, Swedish
International Development Cooperation Agency, (Sida), Sveavagen 20, S-10525 Stockholm,
Sweden, Fax: (00 46) 8 20 88 64, Tel: (00 46) 8 69 85 169, e-mail: goran.paulsson@sida.se
Switzerland: MARTIN, Jacques (Mr) Senior Adviser (Health & Population), Multilateral Division,
Swiss Agency for Development & Cooperatiorr(SDC), 130 Frei burgstrasse, CH 3003 Bern,
Fax: (00 41) 31 324 13 47, Tel: (00 41) 31 322 34 47, e-mail:
Jacques. martin@desza.admin.ch
United Kingdom: CURREY, Mehtab (Dr) Deputy Chief Adviser, Health and Population,
Department for International Development (DfID), 94 Victoria Street, London, SW1A 5JL,
United Kingdom, Fax: (00 44) 207 917 0425, Tel: (00 44) 207 917 0690, e-mail: mcurrey@dfid.gov.uk
USA: EHMER, Paul (Mr) Deputy Director, Office of Health and Nutrition, Bureau for Global
Programmes, Field Support and Research, US Agency for International Development, 1300
Pennsylvania Avenue, NW, Washington, DC 20523, USA, Fax: (00 1) 202 21 63 455, Tel: (00
1) 202 712 1291, e-mail: pehmer@usaid.gov
USA: KIRKLAND, James R. (Mr) Associate Assistant Administrator/Deputy Director, Centre for
Population Health and Nutrition, Global Programmes Field Support and Research, United
States Agency for International Development, 1300 Pennsylvania Avenue, NW, Washington,
DC 20523, USA, Fax: (00 1) 202 21 63 455, Tel: (00 1)202 712 4120,
e-mail: rkirkland@usaid.gov
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Permanent Missions
Belgium: RAYEE, Guy (Mr) Permanent Mission of Belgium, 58 rue Moillebeau, Case postale
473, 1211 Geneva 19, Fax: (00 41) 22 733 5757, Tel: (00 41) 22 733 57 55,
e-mail: badc.ch@ties.itu.int
Italy: QUINTAVALLE, Natalia (Ms), Counsellor, Permanent Mission of Italy, 10 Ch. Imperatrice,
1292 Chambersy, Geneva, Switzerland, Fax: (00 41) 22 734 6702, Tel: (00 41) 22 918 0810
Japan: YOKOMAKU Akito (Ms) First Secretary, Permanent Mission of Japan, 3 chemin des
Fins, case postale 337, 1211 Geneva 19, Switzerland, Fax: (00 41) 22 788 38 11, Tel: (00 41)
22 717 31 07, e-mail: akito.yokomaku@mofa.go.jp
Norway: CHRISTIANSEN, Ottar (Dr) Counsellor, Permanent Mission of Norway, 1211 Geneva
19, Switzerland, Fax: 00 41 22 918 04 10, Tel: 918 04 30, e-mail: ottar.christiansen@mfa.no
South Africa: JOHNS, Desmond (Dr) Counsellor, Permanent Mission of the Republic of South
Africa, rue du Rhone, 65, 1204 Geneva, Fax: (00 41) 22 849 54 32, Tel: (00 41) 22 849 54 42,
e-mail: desmond.johns@itu.ch
Switzerland: BERGER, Martine (Dr) Special Adviser for Public Health and Development, Swiss
Agency for Development & Cooperation (SDC), Permanent Mission of Switzerland, Rue de
Varembe 9-11, Case postale 194, 1211 Geneve 20, Fax: (00 41) 22 749 24 37, Tel: (00 41)
22 749 24 76, e-mail: martine.berger@deza.admin.ch
Civil Society Organizations
BHUIYA, Abbas (Dr) Head, Social & Behavioural Sciences Programme, International Centre for
Diarrhoeal Disease Research, Mohakhali, Dhaka, 1212, Bangladesh, Fax: (00 880) 2 88
26050, Tel: (00 880) 2 88 12914, e-mail: abbas@icddrb.org
DEBIONNE, Francois-Paul (Dr) Deputy Delegate of the International Movement ATD Fourth
World to the Council of Europe, 69 rue General Conrad, 6700 Strasbourg, France,
Fax: (00 33) 3 887 8092, Tel: (00 33) 88 612 784, e-mail: francoispaul.debionne@sante.gouv.fr/debionne@cybercable.fr
DREW, Roger (Dr) Executive Director, Healthlink Worldwide, 40 Adler Street, Cityside, London
E1 1EE, UK, Fax: (00 44) 207 539 1580, Tel: (00 44) 207 539 1577,
e-mail: drew.r@healthlink.org.uk
FISHER, Eleanor (Dr) Social Development Consultant/Lecturer, Centre for Development
Studies, University of Wales, Swansea, SA2 8PP, United Kingdom, Fax: (00 44 )1792 265682,
Tel: (0044) 1792 205678 x 4351 e-mail: Fisher@swansea-ac.uk
HARCOURT, Wendy (Ms) Director Programmes, Editor Development, Society for International
Development, via Panisperna, 207, 00184 Rome, Italy, Fax: (00 39) 06 4872170, Tel: (00 39)
06 4872172, e-mail: wendyh@sidint.org
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HOLLAND, Jeremy (Mr) Lecturer & Social Development Consultant, Centre for Development
Studies, University of Wales Swansea, United Kingdom, Fax: (00 44) 179 226 56 82, Tel:
(0044) 1792 20 5678 e-mail: holland@swansea.ac.uk
KASEJE, Dan (Dr) Tropical Institute of Community Health and Development (TICH) in Africa,
P.O. Box 60827, Musa Gitau Road, Off Waiyaki Way, Nairobi, Kenya, Fax : (00 254) 2 440 306,
Tel: (00 254) 2 44 10 46, e-mail: tichnbi@net2000ke.com
LLORIN, Jean (Ms) Alternate Commissioner, national Anti-Poverty Commission/President,
Bicol Habitat Foundation, 10 Cathedral St. Ateneo Avenue, Naga City 4400, Philippines, Fax:
(00 63) 54 811 27 94, Tel: (00 63) 54 472 64 97, e-mail: kjmarx@mailcity.com
McCORD, Anna (Ms) International Advocacy Coordinator, Save the Children, 17 Grove Lane,
Camberwell, London SE5 8RD, UK, Fax: (00 44) 20 77 93 76 10, Tel: (00 44) 20 77 03 54 00,
e-mail: a.mccord@scfuk.org.uk
MIRZA, Zafar (Dr) Executive Coordinator, The Network for Consumer Protection, 60 A St 39, F10/4 Islamabad, Pakistan, Fax: (00 92) 51 28 17 55, Tel: (00 92) 51 29 15 52,
e-mail: netcp@apollo.net.pk
NANGAWE, Eli (Dr) Deputy Director, Health, Christian Social Services Commission, 4 Ali
Hassan Mwinyi Road, P.O. Box 9433 Dares Salamme, Tanzania, Fax: (00 255) 51 11 8552,
Tel: (00 255) 51 112918, e-mail: cssctz@maf.org
NORDBERG, Olle (Dr) Executive Director, Dag Hammarskjdld Foundation, Ovre Slottsgatan 2,
SE-733 10 Uppsala, Sweden, Fax: (00 46) 18 122072, Tel: (00 46) 18 1272 72,
e-mail: olle.nordberg@dhf.uu.se
RAGHURAM, Sobha (Dr) Deputy Director, Humanistic Institute for Cooperation with
Developing Countries, (HIVOS India), Flat no 402, Eden Park, 20, Vittal Mallya Road,
Bangalore 560 001, India, Fax: (00 91) 8 0227 0367, Tel: (00 91) 11 331 78 04, e-mail:
s.raghuram@hivos-india.org
ROWSON, Michael ((Mr) Assistant Director, MEDACT, 601 Holloway Road, London, N19 4DJ,
UK, Fax: (00 44) 207 281 5717, Tel: (00 44) 207 272 2020, e-mail: mikerowson@medact.org
WIRTH, Meg (Ms) Programme Coordinator, Global Health Equity Initiative, The Rockefeller
Foundation, 420 Fifth Avenue, NY 10018, USA, Fax: (00 1) 212 852 8390, Tel: (00 1) 212 852
8323, e-mail: mwirth@rockfound.org
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Academic Institutions
BLOOM, David (Professor) Professor of Economics and Demography, School of Public Health,
Harvard University, 677 Huntington Avenue, Boston, MA 02115, Fax: (00 617) 566-0365 Tel:
(00 617) 432 0654, e-mail: dbloom@hsph.harvard.edu
BRAVEMAN, Paula (Dr), Professor of Family and Community Medicine, Clinical Professor of
Epidemiology and Biostatistics, University of California, San Francisco, 500 Parnassus Avenue,
Room MU-306E, San Francisco, California, USA, Fax: (00 1) 415 476 6051, Tel: (00 1) 415
476 6839, e-mail: pbrave@itsa.ucsf.edu
CANNING, David (Professor) Queens University, Department of Management & Economics,
Belfast, University Road, Belfast, BT7 1NN, UK, Fax: (00 44) 1 232 236601, Tel: (00 44) 1
232 273281, e-mail d.canning@qub.ac.uk
FUSTUKIAN, Suzanne (Ms) Research Fellow, Health Policy Unit, Department of Public Health
and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1F
7HT, UK, Fax: (00 44) 207 637 53 91, Tel: (00 44) 207 927 2275, e-mail:
suzanne.fustukian@lshtm.ac.uk
GUEDIRA, M. Najib (Professor) Enseignant a la Faculte de Droit de Rabat (Department
d'economie), Conseiller municipal, Cooperative Al Qods, Apt E1, Hy Guich des Oudayas, 10
100 Rabat, Morocco, Tel: (00 212) 760 2271, e-mail: nguedira@mtds.com
HAINES, Andrew (Professor) Head of Department, Primary Care and Population Sciences,
RFUCSM, Rowland Hill Street, London, NW3 2PF, UK, Fax: (00 44) 207 833 2339, Tel: (00
44) 207 833 2338, e.mail: a.haines@ucla.ac.uk
KAWACHI, Ichiro (Professor) Harvard University, 1350 Massachusetts Avenue, Cambridge,
Massachusetts 02138, USA, Fax: (00 1) 617 495 2900, Tel: (00 1) 617 432 0235,
e-mail: ichiro.kawachi@channing.harvard.edu
KOIVUSALO, Meri (Ms) Senior Researcher, Globalism and Social Policy Programme,
STAKES, P.O. Box 220, 00531 Helsinki, Finland, Fax: (00 358) 9 3967 24 17, Tel: (00 358) 9
3967 2110, e-mail: meri.koivusalo@stakes.fi
OYEN, Else (Professor) Chair of CROP, The Comparative Research Programme on Poverty,
Health & Social Policy Studies, University of Bergen, Fosswinckelsgate 7, Norway, Fax: (00
47) 5558 9745, Tel: (00 47) 5558 9740, e-mail: else-oyen@helsos.uib.no
PICK, William (Professor) Head, Department of Community Health, Medical School, University
of Witwatersrand, 1 York Road, Parktown, 2193 South Africa, Fax: (00 27) 11 717 2084, Tel:
(00 27) 11 647 2543, e-mail: maureen@orion.wits.ac.za
ROSLING, Hans (Professor) Professor of International Health, Karolinska Institutet, SE-171 76
Stockholm, Sweden, Fax: (00 46) 8 311 590, Tel: (00 46) 8 51 76498,
e-mail: hans.rosling@phs.ki.se
SEN, Binayak (Professor) BIDS Bangladesh Institute of Development Studies, E-17, Agargaon,
Sher-e-Bangla Nagar, Dhaka 1207, Bangladesh, Fax: (00 880) 2 813 023, Tel: (00 880) 2 316
959 811 23 97,e-mail: bsen@bdonline.com
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SITTHI-AMORN, Chitr (Dr) Dean, The College of Public Health, Chulalongkorn University,
College of Public Health, 10th Floor, Health Science Building 3, Chula Soi 62, Patumwon,
Bangkok, 10330, Thailand, Fax: (00 662) 255 6046, Tel: (00 662) 218 8180, e-mail:
chitr@md2.md.chula.ac.th
STANDING, Hilary (Dr), Fellow, Institute of Development Studies, University of Sussex,
Brighton, BN1 9RE, UK, Fax: (00 44) 1 273 62 12 02, Tel: (00 44) 1 273 678 450,
e-mail: hstanding@compuserve.com
Multi lateral bodies, regional banks, UN agencies
ADEYI, Soji (Dr) UNAIDS, 20 Avenue Appia, CH 1211 Geneva 27, Switzerland, Fax: (0041) 22
791 36 66, Tel: (0041) 22 791 4187
BAILE, Stephanie (Ms) Principal Administrator, Development Cooperation Directorate,
Organisation de Cooperation et de Developpement Economiques (OECD), 2 rue Andre-Pascal,
F-75775 Paris Cedex 16, Fax: (00 33) 1 45 24 19 96, Tel: (00 33) 1 45 24 89 61
e-mail: stephanie.baile@oecd.org
CLEVES, Julia (Dr) UNAIDS, 20 Avenue Appia, CH 1211 Geneva 27, Switzerland, Fax: (0041)
22 791 36 66, Tel: (0041) 22 791 4187
DODD, Nicholas (Mr) Chief, Technical Branch -TPD, United Nations Population Fund
(UNFPA), 220 East 42nd Street, New York, NY, 10017, USA, Fax: (00 1) 212 297 51 45, Tel:
(00 1) 212 297 52 21, e-mail: dodd@unfpa.org
FAURE, Jean-Claude (Dr) President du Comite d'Aide au Developpement (CAD), Chairman,
DAC/OECD, 2 rue Andre Pascal, 750016 Paris, France, Fax: (00 33) 1 44 30 6141, Tel: (00
33)1 45 24 9070, e-mail: j-claude.faure@oecd.org
FRANSEN, Lieve (Dr) Principal Administrator, Social Development Unit, Directorate-General
VIII, Euroeapn Commission, rue de la Loi 200, B-1049 Brussels, Belgium, Fax: (00 32 ) 2 296
36 97, Tel: (00 32) 2 296 36 98, e-mail: lieve.fransen@cec.eu.int
VAN DEN BUSSCHE, Inge (Ms) European Commission, rue de la Loi 200, B-1049 Brussels,
Belgium, Fax: (00 32 ) 2 296 36 97
GRANT Stephanie (Ms) Chief, Research & Right to Development Branch, Office of the High
Commissioner for Human Rights, ONOG-OHCHR, 1211 Geneva 10; Switzerland, Fax: (00 41)
22 917 90 10, Tel: (00 41) 22 917 91 02, e-mail: sgrant.hchr@unog.ch
GREENE, Edward (Dr) Assistant Secretary-General of Human and Social Development,
Caribbean Community (CARICOM) Secretariat, Bank of Guyana, Main Street, Georgetown,
Guyana, South America, Fax: (00 592) 2 50 871, Tel: (00 592) 2 544 93,
e-mail: egreene@caricom.org
GUINNESS, Lorna (Ms) UNAIDS, 20 Avenue Appia, CH 1211 Geneva 27, Switzerland, Fax:
(0041) 22 791 4741, Tel: (0041) 22 791 4917, e-mail: guinnessl@unaids.org
JURGENS GENEVOIS, Ilona (Mrs) Programme Officer, UNDP, Palais des Nations, CH-1211
Geneva, Tel: (00 41) 22 917 8287, e-mail: ilona.jurgens.genevois@undp.org
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MEILLAN, Laurent (Mr) Associate Human Rights Officer, Research and Right to Development
Branch, Office of the High Commissioner for Human Rights, Palais Wilson, Office 4-092, Palais
des Nations, 1211 Geneva 10, Switzerland, Fax: (00 41) 22 917 9010, Tel: (00 41)22 917
9192, e-mail: lmeillan.hchr@unog.ch
MIERZEWSKI, Piotr (Mr) Council of Europe, Directorate General Ill-Social Cohesion, Health
Department, 67075 Strasbourg-Cedex, France, Fax: (00 33) 3 884 12 726, Tel: (00 33) 3 88
41 30 04, e-mail: piotr.mierzewski@coe.int
NIZAMUDDIN, Mohammad (Mr), Director, Technical and Policy Division, United Nations
Population Fund, 220 East 42nd Street, New York, New York 10017, USA, Fax: (00 1) 212 297
4915, Tel: (00 1) 212 297 5211, e-mail: nizamuddin@fpawh.unfpa.org
OBAID, Thoraya A (Ms), Director, Division for Arab States and Europe, United Nations
Population Fund, 220 East 42nd Street, New York, New York 10017. Fax: (00 1)212 297 4905,
Tel: (001)212 297 5291, e-mail: obaid@unfpa.org
PYAKURYAL, Kiran (Mr) Chief, Rural Development Section, United Nations Economic and
Social Commission for Asia and the Pacific, UN Building, Rajdamnern Avenue, Bangkok
10200, Thailand, Fax: (00 662) 288 1056, Tel: (00 662) 288 1390, e-mail:
pyakuryal.unescap@un.org
SAIGAL, Jagdish (Mr) Senior Programme Manager, UNCTAD/UNDP Global Programme on
Globalization, Liberalization and Sustainable Human Development, E-7024 Palais des Nations,
1211 Geneva 10, Geneva, Switzerland, Tel: (00 41) 22 776 42 89, e-mail:
jagdish.saigal@unctad.org
SAHAMI-MALMBERG, Masoumeh (Mrs), Economic Affairs Officer, Office of the Special
Coordinator for LDCs, UNCTAD. Palais des Nations, CH-1211 Geneva 10, Fax: (00 41) 22
917 00 50, Tel: (00 41) 22 917 55 37, e-mail: masoumeh.malmberg@unctad.org
STERN Marc (Dr), Bureau for Development Policy Office of development Studies (ODS),
United Nations Development Programme, UH -401, 336 East 45th Street, New York, NY 10017
USA, Fax: (00 1) 212 906 36 76, Tel: (00 1) 212 906 36 80, e-mail: marc.stern@undp.org
VANDEMOORTELE, Jan (Mr) Chief of Policy and Analysis in UNICEF, 3 United Nations Plaza,
New York, NY 10017, USA, Fax: (00 1 212) 888 7465, e-mail: jvandermoortele@unicef.org
World Bank
GWATKIN, David (Dr) Principal Health and Poverty Specialist, World Bank, 1818 H Street, NW,
Washington, DC 20433, USA, Fax: (00 1) 202 522 3234, Tel: (00 1) 202 473 3223, e-mail:
dgwatkin@worldbank.org
KLUGMAN, Jeni (Dr) Senior Economist, Poverty Reduction & Economic Management Network,
The World Bank, 1818 H Street, N.W., Washington, D.C. 20433, Fax: (00 1) 202 522 3234,
Tel: (00 1) 202 458 5520/5125, e-mail: jklugman@worldbank.org
LOVELACE, Christopher (Dr) Director, Health, Nutrition,and Population Department, The World
Bank, 1818 H Street, N.W., Washington, D.C. 20433, Fax: (00 1) 202 522 3234, Tel: (00 1) 202
458 5520/5125, e-mail: jlovelace@worldbank.org
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NARAYAN, Deepa (Ms) Principal Social Development Specialist, Poverty Division, Poverty
Reduction & Economic Management Department, World Bank, 1818 H Street, NW,
Washington, DC 20433, USA, Fax: (00 1) 202 522 32 34, Tel: (00 1) 202 473 9475, e-mail:
dnarayan@worldbank.org
PETERS, David (Dr) Senior Public Health Specialist, India Resident Mission, World Bank, 1818
H St. NW, Washington, DC, 20433, USA, Fax: (00 1) 91 11 461 9393, Tel: (00 91) 11 461
7241, e-mail: dpeters1@worldbank.org
PREKER, Alexander (Mr) Lead Economist, HDNHE, World Bank, 1818 H St, NW, Washington,
DC 20433, USA, Fax: (00 1) 202 522 3234, e-mail: apreker@worldbank.org
YAZBEK, Abdo (Mr) Senior Health Economist, South Asia Region, World Bank, 1818 H St,
NW, Washington, DC 20433, USA, Fax: (00 1) 202 522 3234, Tel: (00 1) 202 473 0847,
ayazbek@worldbank.org
WHO Regional Offices
ANIKPO N'TAME, Emilienne (Dr) Director, Healthy Environments and Sustainable
Development, WHO Regional Office for Africa, Fax: (00 1) 407 733 9001, Tel: (00 263) 11 403
506, e-mail: anikpoe@whoafr.org
CASAS, Juan Antonio (Dr), Director, Division of Health & Human Development, WHO Regional
Office for the Americas, Fax: (00 1) 202 974 3652, Tel: (00 1) 202 974 3210, e-mail:
casasjua@paho.org
SHEIKH, Mubashar, R. (Dr) Regional Adviser, Health Care Delivery, Department of Health
Systems & Community Development, WHO Regional Office for the Eastern Mediterranean,
Fax: (00 203) 4824 329, Tel: (00 203) 48 70 090, e-mail: mubashar@who.sci.eg
RITSATAKIS, Anna (Dr) Head, WHO European Centre for Health Policy, c/o Ministere des
Affaires Sociales, de la sante publique et de I’Environnement, Brussels, Fax: (00 32) 02 210 50
37, Tel: (00 32) 02 210 59 14, e-mail: anna-ritsatakis@health.fgov.be
KRECH, Rudiger (Dr), Technical Adviser, Health Promotion and Investment for Health, WHO
Regional Office for Europe, Fax: (00 45) 39 17 1818, Tel: (00 45) 39 17 12 69, e-mail:
rkr@who.dk
LAMBA, B. (Mr) Health for All Office, WHO Regional Office for South-East Asia, Fax: (00 91)
11 331 8607, Tel: (00 91) 11 331 7804, e-mail: lambab@whosea.org
RON, Aviva (Dr) Director, Health Sector Development, Regional Office for Western Pacific,
Fax: (00 63) 2 521 1036, Tel: (00 63) 2 528 9951, e-mail: rona@who.org.ph
WHO Country Representatives
MOHAMUD, Bile, Khalif (Dr) WHO Representative in Islamic Republic of Iran, Ministry of
Health, Tehran, Fax: (00 98) 21 670 89 69, Tel: (00 98) 21 67 00 361, e-mail:
BRUDON, Pascale (Dr) WHO Representative in Vietnam, World Health Organization, 2A Van
Phuc, P.O. Box 52, Hanoi, Vietnam, Fax: (00 84) 4 823 3301, Tel: (00 84) 4 845 7901,
e-mail: who@vtn.wpro.who.int
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MWAMBAZI, Wedson (Dr) WHO Representative in Tanzania, World Health Organization, P.O.
Box 9292, Dar es Salaam, Tanzania, Fax: (00 255 ) 51 11 31 80, Tel: (00 255) 51 13 27 84,
e-mail: mwambazi@who.or.tz
PETKEVICIUS, Robertas (Dr), Liaison Officer, WHO Liaison Office in Lithuania, c/o Ministry of
Health, Room 304, Vilniaus Str. 33, LT-2001 Vilnius, Lithuania, Fax: (00 370) 2 22 66 05, Tel:
(00 370) 2 22 67 43, e-mail: ltwho@ktl.mii.it
TANKARI, Kadri (Dr), WHO Representative in Senegal, 22 boulevard Djily Mbaye, Dakar,
Senegal, Fax: (00 221) 823 3255, Tel.(00 221) 823 0270, e-mail: omsdakar@telecomplus.sn
WALIA, Tej (Dr), Deputy WHO Representative to India, WHO, 534 A-Wing Nirman Bhavan,
Maulana Azad Road, New Delhi-110 011, India, Fax: (00 91) 11 301 2450, Tel: (00 91) 11 301
89 55, e-mail: waliat@whoindia.org
WHO Secretariat
20 Avenue Appia, CH 1211 Geneva 27, Switzerland. Tel: (0041) 22 791 2111
e-mail: last name, initial of first name @who.int
example : ACHARYA Shambhu - e-mail: acharyas@who.int
ACHARYA, Shambhu (Dr)
BANDA, James (Dr) RBM
BEAGLEHOLE, Robert (Professor) HSD
BLAS, Erik (Mr) CRD
BONITA, Ruth CCS
CASSELS, Andrew (Dr) DGO
CREESE, Andrew EDM
DORKENOO, Efua (Ms) WMH
DRAGER, Nick (Dr) HSD
DZENOWAGIS, Joan (Dr) CCS
DUBE, Siddharth (Mr) HSD
FLORISSE, Sonia (Ms) HSD
FRENK, Julio (Dr) EIP
HARTMANN, Paolo (Dr) HSD
HODGE Matthew (Mr) HSD
HU Shasa, HSD
JANOVSKY, Katja (Dr) SCP
KATZ, A. (Ms) HIV/AIDS/STI Initiative (HIS)
LIPSON, Debra (Ms) HSD
MARTIN, John (Dr) HSD
MURRAY, Christopher (Dr) GPE
MURTHY, Srinavasa (Dr) MSD
NABARRO, David (Dr) DGO
NYGREN-KRUG, Helena (Mrs) HSD
OLEJAS, Steven (Mr) HSD
PFLEGER, Bruce (Dr) MNC/CRA
REGIS, Lisa (Ms) HSD
RENGANATHAN, Elil (Dr) CPE
ROBINSON, Helen (Ms) GMG
SHENGALIA, Bakuti (Dr) HSD
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SIMS, Jacqueline (Ms) HSD
SINGH, Poonam Khetrapal (Mrs) SDE
SKOLD, Margareta (Ms) HSD
SPINACI, Sergio (Dr) CDS
VON SCHIRNDING, Yasmin (Dr) HSD
VILLAR, Eugenio (Dr) HSD
WALLSTAM, Eva (Mrs) HSD
WHEELER, Mark (Mr) HSD
WOODWARD, David (Mr) HSD
YACH, Derek (Dr) NMH
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