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TURNING HEALTH INTO AN INVESTMENT:
the latest high-power assaults on third world health care
Keynote address by David Werner
Seminar of Health Communications
Xavier Institute of Communications
25th Anniversary
17 November, 1994
Available tronr
healYhWrights
Wifcgpxp for foopie*i Haith nd Rights
964 Hamilton Avenue
Palo Alto, CA 94301, USA
Telephone: (415) 325-7500
FAX: (415) 325-1080
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TURNING HEALTH INTO AN INVESTMENT:
THE LATEST HIGH-POWER ASSAULTS ON THIRD WORLD HEALTH CARE
— David Werner —
Tit topic I have been asked to address is "Health in Developing Countries: an Overview of Emerging Issues."
Current trends in health and health care are, of course, part of a conservative, distressingly regressive, global trend
and must be examined within this broader context.
In spite of the acclairred goal of Health fcr All, in recent years formal health services have become increasingly
inaccessible for die growing numbers of destitute people. The reason largely economic. At the same time that
poverty is deepening in many nations, rich and poor, the costs for basic health care are being systematically shifted
from the public sector to the individual consumer.
Since the early 1980s the income gap between rich and poor has been widening between countries and within them.
Today over one billion persons—one in five of the world's people—try to survive on less than one dollar per day.1
In many countries, minimum wages have fallen so low tliat they do not cover the family’s basic food needs. On a
recent visit to Bolivia. I was told it now' takes seveti official minimum wages to adequately feed a family of five,
No wonder a lot of Bolivians grow coca—-or chew it to stave off hunger! And no wonder over half of Bolivia's
children show signs of stunting!2
Too often high-level health and developrtun". planners get so absorbed io macro issues of health economics that they
lose sight of the micro (or human) issues. They focus on how health ministries faced with increasing demands and
shrinking budgets can function "cost effectively." rather than on how impoverished families can cope with falling
wages and rising costs of both food and health services. Little research has been done to examine the extent to
which the. money poor families spend on betJ th care affects the nutritional status, and thereby on health and survival,
especially of women and children Yet such questions arc of crucial importance when considering the current trends
toward privatization and cost recovery.
The colonial and neocolonlal medical model
Ever since the Western Medical Model was introduced into Southern countries in colonial times, it has been a two
edged sword. Its urban-based, doctor coatrclled, expensively equipped "disease palaces" have always catered to the
privileged.’ The few health services directed at the 'natives' were mainly designed to keep them productively
working in plantations- and/or factories owatd by the rich. Thus in the coiotnai era, health for tbs poor was not seen
as a right, but as a requirement for well-managed performance of labor. (As we shall discuss, the World Bank's new
mandate for Investing in Health, with its emphasis on cost effectiveness for productive contribution to the global
economy, is a regression to this colonial mind-set.)
In the post-Worid War II era. there was an evolving social consciousness that all people are entitled to the same basic
rights and that society has a responsibility Io make sure the basic needs of all people are met, regardless of gender,
race, class, and relative ability or disability. As a pan of Uris new basic needs approach, development planners
sought ways to make Western medical and health services more widely accessible to underserved Third World
communities. Thus rural dispensaries were set up and staffed by modestly-trained health auxiliaries. While this "rural
penetration" of Western medicine brought tome benefits, it also created new problems. One was added costs to
consumers. Even where services were sulaidized, travel to the dispensaries, which were few and far between.
2
Involved time and expense. .Medicines, when available, were often costly; or sick persons were referred to a distant
hospital at still greater costs to lite poor farrily. Under the influence of new wander drugs, people's faith in low-cost
borne remedies began to decline "A pill for every ill" became standard treatment and injections acquired a magical
ethos. Budding multinational pharmaceutical conurajues capitalized on this growing drug dependency. The
medicalization and commercialization of tiealtb care, together with an erosion of traditional forms of self-care,
became a growing obstacle to health.
Health ewe as an obstacle to health: an example from the Philippines
Several years ago a group of village health workers from Mexico and Central America went to the Philippines to
exchange ideas.
Near Tadoban we visited the Makapawa community-based health program. Among other
innovations, local health workers had organized neighborhood groups to make their own herbal medicines for
common ailments. These combined traditional lore with modem science. Cough and cold syrups contained bitter
orange, high in Vitamin C. An 'ABC drink' for diarrhea was an oral rehydratioo mix with tasty herbs added. In
silbedees.
women, srd cbt’dren hxW p®»» !o ry*r"<-n'(s
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The Makapawa health workers proudly told us that after only two years child malnutrition and mortality had
decreased. We asked why. They said it might be the nutrition training for mothers during 'under fives' clinics. But
the mothers present said, 'Not so! For years visiting nurses have lectured us on how to feed our children. If we
don't feed them right, its for lack of money, not know-how.' Yet the mothers confirmed that current wages were
lower than before. So why, we asked, liad their children's health improved? At first, no one had an answer.
We asked how much the mothers were spending ext health care: herbal medicines, modern medicines, travel to
doctors. etc. The average turned out to be 10 to 12% of family earnings. We said this was low compared to other
lands we had visited, where some poor families spent 30% or more of their earnings on health-related expenses.
Then one mother said, "We don't spend nearly as much now as we used to." Others agreed. Before the program
began some families had spent over 40% of their earnings on health-related costs. Their hungry children were
constantly getting sick. A family would first spend on a witch doctor, then oo modem tonics and cough syrups, and
finally on costly trips to city doctors and hospitals In emergencies they had to borrow from loan sharks,' and pay
back for years. If their children recovered, little money was left to feed them, and soon they fell ill again.
•But now when our children have coughs or edds or diarrhea we give them our home-made medicines," explained
one mother. "That leaves more money for food (and for medical help when really needed). So our children are fatter
and get sick less often. We save even mote on health expenses, so we can feed our children still better! And now
they die less often!"
"You know what we're saying!" exclaimed one mother. "We're saying it was what we wen spending on health can
that was killing our babies.'' Thus the mothers recognized that by avoiding some of the high costs of commercial
medicine. and by rediscovering the value of certain traditional forms of healing, they could better protect their
children's health. Another factor, they realized, was that their liealth workers had helped them organize and share
in times of need, to avoid falling prey to the loan sharks 4
The birth and death of Primary Health Care
By the late 1970s, wide recognition that the Western medical model was still failing to adequately improve Third
World health levels led to growing demand fix reform. In 1978 the World Health Organization (WHO) and UNICEF
convened the famed global conference endorsing the Alma Ata Declaration. To advance toward Health for All by
the Year 2000, the Declaration called for a potentially revolutionary approach. Primary Health Care (PHC) was
3
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conceived as a comprehensive strategy that would not only include an equitable, consumer-centered approach to
bcAiib services, bur would addiess 41*; uaiuii/iog voJji and political ocierwinaiiLs or beaim.
It called for
accountability of health workers and health ministries to the common people, and for social guarantees to make sure
that the basic needs—including food needs of alf people are met. In recognition that socially progressive change
only comes from organized demand, it called for strong popular participation.
Unhappily, these high expectations of Alma Ata have not been met. Today, 17 years later, it is painfully evident
that the goal of Health for All is growing more distant, not just for the poor, but for humanity. Some critics say that
Primary Health Care has failed. Others protest that it has never really been tried.
Strategically, there have been three major events that have sabotaged the revolutionary essence of Primary Health
Care; 1) the introduction of Selective Primary Health Care at the end of the 1970s, 2) Structural Adjustment
Programs and the push for User-financed Health Services, introduced in 1980s, and 3) the take aver of Third World
health care policy-making by the World Bank in the 1990s. All three of these monumental assaults on Primary
Health Care are a reflection of the prevailirg regressive sociopolitical and economic trend*.
1.
Selective Primary Health Care
No sooner had the dust settled from the Ahna Ata Conference in 1978, than top-ranking health experts in the North
began to trim the wings of Primary Health Care. They asserted that, in view of the global recession and shrinking
health budgets, such a comprehensive approach would be too costly. If any health statistics were to be improved,
they argued, high risk groups must be "targeted" with a few cost-effective interventions. This new politicallysanitized version of PHC was dubbed Selective Primary Health Care.
UNICEF bad been a strong advocate of Comprehensive Primary Health Care as declared at Aims Ata. But frustrated
by the unwillingness of major donor agencies and health ministries to seriously promote such a radical model, and
pressured by the socially retrograde political climate of the 80s, UNICEF soon compromised. It began to advocate
Selective PHC as being more "realistic." Through its so-called Child Survival Revolution— which some critics called
a counter-revolution—UNICEF prioritized four interventions known as GOBI (Growth monitoring, Oral rebydraticc
therapy (ORT), Breast feeding, and Immunization). UNICEF later attempted to broaden its limited package of health
technologies to GOB1-FFF (adding Food supplements. Female education, and Fartrily planning). But in practice, in
most countries PHC became even more selectively reduced to the twin engines of Child Survival: ORT and
Immunization.
The global Child Survival Campaign quickly woo high-level support. For those in positions of privilege and power.
it was safe and politically useful. It promised to improve a widely accepted health indicator, namely child mortality,
while it prudently skirted (except in rhetoric) the social and economic inequities underlying poor health. Not
surprisingly, many health professionals, governments, and USAID quickly jumped on the Child Survival bandwagon.
Even the World Bank—which bad previously not put much investment in health—began to lend its support.
But technological solutions can only go so far in combating health problems whose roots are social and political.
Predictably, the Child Survival initiative lias had Jess impact than was hoped. Over 13 million children still die each
year (roughly the same number as 15 years ago. although the percentage is somewlat reduced). Mo»t of these deaths
still are related to poverty and undemutritior..
It has become increasingly clear that reducing child mortality through selected technological interventions does not
necessarily improve cldldren's health or quality of life, especially if they do little to combat poverty or improve living
standards. During the 1980s a disturbing pattern began to emerge in the health indicators of some poor countries:
while child mortality rates dropped, undemutritlori and morbidity rates increased. Such a pattern bodes an ominous
4
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ennngh in rtv- lar*> WCk and early 90s. in many rniinrries rhp ■lectin* in child mortality
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now- slowed or baited, and in several countries (especially in sub-Saharan Africa) child mortality is increasing/
Equally disturbing, Lbe two most heavily promoted technologies for reducing child mortality are proving difficult to
sustain. Since the start of the 90s, litere has been a backslide both in Oral Rebydration Therapy usage and
Immunization coverage
The recent decline in immunization and corresponding increase in polio cases are shown
on the two graphs from UNICEFs Stale of the World's Children Report, 1994. As for oral rebydration, even Egypt's
national program—long upheld as the great success story—has in the 90s experienced a precipitous decline in ORS
usage rates: from more than 50%, down to 23%.'
[Include here graphs from UNICEF’s SWCR 94, with appropriate captions and rets.]
The disappointing and in some countries diminishing Impact of Oral Rehydration Therapy can in part be explained
by structural adjustment policies, which haw methodically shifted the costs of health services and products onto dr
poor. But it is partly due to the dependency-creating, disempowering way the technology was introduced.
As we all know, there are two basic approaches to ORT: (1) manufactured packets of Oral Rebydration Salts (ORS),
and (2) "borne fluids." Strong encouragement of appropriate home fluids promotes greater self-reliance and control
over diarrheal disease at the family and community level. Home fluids are less costly, more rapidly and reliably
available, when prepared with cereals or starches can be safer and more effective than the sugar-based ORS formula.
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But from the start. WHO, UNICEF, and USAID put their biggest investment into factory-made packets, thus
pharmaceutical! ci ng a "oLmplc solution" and crcadog dependency on u product whose price and a'ail ability Lie uuudQc
family and community control At first OHS jackets were distributed free But when health budgets were slashed
by adjustment policies, health ministries were pressured to pnvatize both production and distribution. This
CTtfnnv.fCiMlizAtirHi of * prrfF.nfially "It fa saving technology.** nvan« That rnrtay many p»r families epend up to orw
fourth of ihPtir dwy's wage for or** parket of OR‘n Sinrp nnrWnntfirinn is fly? predisposing oauoa of d^alh from
diarrhea, it is easy to see how social marketing that induces poor families to spend their limited food money on ORS
packets may be counterproductive in terms of lowering child mortality. However, virtually no studies have been
done tn rWtermtnp hnw fumity expend'Ul*OR5 PVXX nAgortwty
^h»ld nutrition and cuz-.-i-val.
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Apart from promoting needless spending by poor families, privatization of ORS has made teaching about oral
rehydration more problematic. As you know, here in India there is an array of ORS products on the market,
designed for mixing with quantities of water ranging from 1 filer to 1/3, 1/4 and 1/5 of a liter. This wide variation
makes it impossible to teach families bow to mix a safe an effective ORS drink. All the health worker can tell
mothers is, "Follow the instructions on each packet." But in a laud where most women cannot read, following such
instructions is not easy The probability of preparing dangerously concentrated ORS drinks has increased.
Wisely, in the last few years. UNICEF and WHO have begun to place more emptiasis on increased home fluids and
continued feeding (including breast feeding) ratlier titan such disproportionate emphasis on ORS packets. But after
a decade of marketing the packets as a wonder drug, it is proving difficult to reeducate people (and especially health
practitioners) tliat they can save both monej and lives by using appropriate home drinks. Some health activists draw
a parallel between the misdirected promotit® of ORS packets and that of bottle feeding. Both involve commercial
products which are more costly, more nutritionally counterproductive, more dependency-creating, and more
exploitative of tbs poor, than are the corrcs]x®ding home drinks.
Zimbabwe is ooe country that has taken a courageous stand in favor of lions solutions and has refused to use ORS
packets. The Zimbabwe Health Ministry irmly refuses to let ORS packets be used even in health centers, on the
grounds that this would make people think Irame drinks are a second best substitute. Instead, nurses teach mothers
how to prepare and give the same rehydrati,® drinks they are encouraged to use at home.
2.
Structural Adjustment Programs and cost-recovery plans
The next big set-back to Primary Health Care has been the introduction, during the 1980s, of Structural Adjustment
programs (SAPs).
Structural adjustment programs (SAPs)—enpneered by the World Bank and IMF—are, in essence, a way of making
poor people pay for the irresponsible lending by the rich in the North to the rich in the South. By the beginning of
the 80s, the "development" strategies imposed by the North on the South had begun to backfire. The Big is Beautiful
development paradigm—pushed in tl>e 60s and 70s by huge loans from Northern banks—made poor countries more
dependent on the global market with its ruthless ups and downs. With the introduction of large scale, maettineryintensive agribusiness and industry, land and wealth concentrated into fewer hands. Landlessness, unemployment,
poverty, and hunger increased. Growing unrest brought more repressive measures of social control. Even in
coontries that experienced "economic miracles," like Brazil, real earnings of workers drastically declined. Mote
trickled up than trickled down In sum. fa: vast numbers of people development really meant underdevelopment.
It brought deteriorating living conditions aoc denial of basic rights
But troubles were just beginning. By the start of the 80s poor coontries were faced with staggering foreign debt
Huge interest payments offset any betrfits from economic growth. As Third World economies began to falter,
Northern banks withheld new loans, and stores of countries went into a fiscal tailspin. Some—beginning with
6
Mexico 111 1962—anuouiivccl IDe) simply could not pay- The baakj, -with billions of dollars in loatM to poor
countries, feared economic collapse if debtcr countries defaulted on their loans.
Then the World Bank and IMF came to the rescue (primarily of the Northern banks). They gave countries in crisis
hail.out loans to keep servicing their huge debts and hopefully to restore economic growth. But strings were
attached to these loans, mainly in the form of Structural Adjustment Programs. SAPs were designed to rtnsam-line
poor country economies so as to free up money for servicing foreign debt, and to bind poor countries into
international trade accords that favor big business and 'hue market" interests in the North. SAPs have usually
included the following components:
- cutbacks in public spending
- privatization of government enterprises
• freezing of wages and freeing of prices
- increase of production for export rather than for local consumption
- reducing tariffs and regulations and creating incentives to attract foreign capita] and trade
- reducing govemarnt tteficits by charging user fees for social services, including health
o
In sum. such policies add up to "transferring resources to investors and lowering payments to laborers." Inevitably,
they hit the poor hardest. Budgets for so-called "non-productive" government initiatives such as health, education,
and food subsidies were ruthlessly slashed, while bloated military expenditures were mostly left untouched. Public
hospitals and lealth centers were sold to the private sector, pricing their services out of reach of the poor. Falling
real wages, food scarcity, and growing unemployment due to government layoffs all joined to push low-income
1CMUMX1VO UJIV VTMlOVmiJg kArOUlUUVU.
The overall impact of adjustment has been hotly debated. At first the World Bank denied that structural adjustment
has hurt the poor. (This is like the tobacco industry saying there is no proof that smoking causes lung cancer.) More
recently, the Bank has conceded that adjusunent may have caused temporary hardships for low income families, but
that such austerity (starvation of children?) is necessary to restore economic growth. Ignoring the historical record,
the Bank still seend to think that by helping the rich get richer, the benefits will somehow trickle down to the poor.
But the evidence is overwhelming that structural adjustment, linked with other conservative trends in recent years,
has caused a major set-back to Third World health.1 The World Bank defends its strategies with reports and graphs
showing that over the past 30 years Third World health has steadily improved. However, these reports shrewdly
downplay the fact that in many countries improvements in health have slowed down or stopped since the mid-80s,
end mon so in the 90s.^ In some countries rates of under-nutrition, tuberculosis, cholera, STDs, plague, malaria,
and other indicators of deteriorating conditions, have been drastically increasing.
In spite of a modicum of development aid from the North, in the 1990s more than $60 billion net flows each year
from the poor countries to the rich. GATT and recent "free trade" agreement, as currently drafted, are more likely
to increase than decrease this inequity. Todty, the income of the richest 20% of the world's inhabitants is 140 times
as great as that of the poorest 20%. And worldwide the gap between rich and poor has grown 30% in the last 10
years. Although enough food is produced in the world to feed all people adequately, according to the UNDP nearly
one quarter of the world's people do not get enough io eat.
UaervOnuKing or cost recovery schemes, together with privatization of public health services are among the
adjustment policies mandated by the World Bank and IMF. UNICEF has also promoted user-financing of village
health posts through the so-called Bamako I.uitiative, now functioning in many African countries and elsewhere.
While UNICEF has some reservations about die Initiative, it argues that in today's hard tines it sees no better
alternative. Cutbacks io health budgets during the 80s resulted in closure of many rural health poets, largely for lack
7
3^B p09
of rredicioes
UNICEF knows that people want medicines and are willing to pay for (bem.
So through Bamako,
consumers are charged enough for drugs to keep the health posts stocked and functioning.
UNICEF has tried to make the Ramako Initiative user-friendly and community controlled (c.f UNICEFs Adjustment
with a Human Face).
Indeed, the program does have a number of positive features. For one, only essential drugs
are used (although, perhaps counterproduct; vely, ORS packets are sold as an ‘essential drug1 for home use). Also,
in some of the Bamako community-run health posts I have visited, local participation has been active and
enthusiastic.
But many cost-recovery schemes have serious—and perhaps life-threatening—drawbacks. Just because poor families
are willing to pay for medicines does not mean they can afford to pay for tlem. .As we saw in the Philippines, poor
families often spend for medicine the last pennies they need to feed their sick children. And when health posts are
financed through sale of drugs, the temptation to over-prescribc is great. Also, because the poorest families get sick
most often and tend to require mere medication, they may carry more than their share of costs for the health post.
While Bamako has provisions to charge less to the poorest cf the poor, such safety nets work better on paper than
in practice.
Studies in some countries have shown that when cost-recovery has been introduced, utilization of health centers by
high risk groups has dropped. For example. in Kenya the introduction of user fees at a center for sexually
transmitted diseases caused a sharp decline in attendance and an increase in untreated STDs.
Whatever their short-term impact, the introduction of these so-called cost-sharing schemes has disturbing long-term
social and ethical implications. It represents a retreat from progressive taxation, where society takes from the
prosperous to benefit the least fortunate, in a sense of fairness and sharing Placed in historical perspective, when
decision makers begin to inflict destitute and undernourished people with an increased portion of health-related costs,
this is a great step backwards It means that for those In greatest need, health care is no longer a human right.
3.
Investing in Health: The World Bank takeover of health policy planning
The World Bank's 1993 World Development Report, Investing in Health, has put the last nail in the coffin of the
Alma Ata Declaration.14
Turning Health into Investment would be a better title, for the Bank takes a
dehumanizi ngiy mechanistic marketplace view of both health and health care When stripped of its humanitarian
rhetoric, its chilling thesis is that the purpose of keeping people healthy is to promote economic growth. Were this
growth to serve the well-being of all, the Bank's intrusion into health care might be more palatable. But the
'economic growth' which the Bank invariably promotes as the goal and measure of "development" has invariably
beoefltted large multinational corporations, often at great human and environmental cost.
The World Bank tells us it has turned over a new leaf: it now recognizes that sustainable development must take
direct measures to eliminate poverty. Yet tie Bank has so consistently financed projects and policies which worsen
the situation of disadvantaged people that we must question its ability to change its course. A growing number of
critics suggest that perhaps the most effective step the World Bank could take to eliminate poverty would be to
eliminate itself.
On first reading, the Bank's strategy for improving health status worldwide sounds comprehensive, even modestly
progressive. It acknowledges the economic roots of ill health, and states that improvements in health are likely to
result primarily from advances in non-hcrlth sectors. It calls for increased family income, better education
(especially for girls), greater access to health care, and a focus on basic health services rather than tertiary and
specialist care. It quite rightly criticizes the persistent inequity and inefficiency of current Third World health
systems. Ironically, in view of its track record of slashing health budgets, it even calls for increased health spending.
... So far so good.
8
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Bui on reading further, we discover that under the guise of promoting an equitable, cost-effective, decentralized, and
country-appropriate Itealth system, the World Bank's key recommendations spring from the same sori of structural
adjustment paradigm that lias worsened poverty and lowered levels of health.
According to the Rank's prescription, in order to save "millions of lives and billions of dollars" governments must
adopt "a three pronged policy approach of health reform:
1.
2.
3.
Foster an enabling environment for households to improve health.
Improve government spending In health.
Promote diversity and competition in the promotion of health services."
These recommendations are said to reflect new thinking. But stripped of their Good Samaritan face lift, and reading
the Report's fine print, we can restate these three prongs more reveallngly:
1. "Foster an enabling environment for households to improve health" means requiring disadvantaged
families to cover the costs of their own health care ... in other words, fee for service and cost recovery
through user financing: putting the burden of health costs back on the shoulders of the poor.
2, “Improve government spending in health" means trimming government spending by reducing services
from comprehensive coverage to a computerized selection of cost-effective measures ... in other words,
a new brand of Selective Primary Health Can.
3. "Promote diversity and competi ion" means turning over to private, profit-making doctors and businesses
most of those government services that used to provide free or subsidized care to the poor ... In other
words, privatization of most medical aid health services: thus pricing many interventions beyond the reach
of those in greatest need.
So we find the Bank's new health policy is old wine in new' bottles: a rehash of the conservative strategies that have
systematically derailed Comprehensive Primary Health Care—but with the added shackles of structural adjustment.
In essence, it is a market-friendly version of Selective Primary Health Care, which includes privatization of medical
services and user-financed cost recovery.
As with other Selective PHC scliernes, it focuses on technological
interventions and glosses over tie social and legislative determinants of health: issues such as legalization of abortion
and abandoned children. One reviewer (David Legge) observes that tlie World Bank Report is "primarily oriented
amend the technical fix rather than any focus on structural causes of poor health; It Is about healthier poverty.'^
The Bank prioritize health interventions by calculating their relative cost effectiveness. This is measured by the
number of Disability Adjusted Life Years (DALYs) saved through each intervention. The cost of each intervention
is weighed against the person's potential 'productivity' (i.e., contribution to economic growth). Each disease and
ailment is classified according to bow many years of productive (disability free) life tlie individual loses as a result,
The Bank has studied and prioriGzed 47 different public health and clinical interventions, expressing their benefits
in DALYs achieved. For example, leukaemia treatment is not cost effective, only 10 DALYs being saved for
$10,000, while Vitamin A supplementation achieves nearly I DALY for $1.
In calculating DALYs. years of productive: life lost are weighted according to age and work potential.
Hence
children and the elderly have lower value than young adults, and presumably disabled persons who are unable to
work are awarded zero value and therefore have Utile or no entitlement to health services at public expense. The
very term Disability Adjusted Life Years is an affront to disabled persons. (The DALY prioritization method which
authoritatively deprecates disability has the stench of eugenics. Disabled activists need to join with heal± rights
activists to protest this potentially neo-fascist policy.)
9
The Investing in Health Report advocates that governments should favor an environment that enables households to
improve health But to do tins Lt does not call loudly for fairer wages or stronger labor unions. Instead, as always,
it recommends economic growth policies becked by structural adjustment jirograms which, it claims, will eventually
raise income per capita. In making this reccmmendatioo, the Bank ignores the fact that in many countries with SAPs
average per capita income has plummeted. Even in countries whose economies have partially recovered, most gains
have been pocketed by the wealthy; poor people's real income lias tended to decline.
With its call for "greater diversity and competition in the provision of health services, promoting competitive
procurement practices, fostering greater Involvement by non-govemmjnt and other private organizations, and
regulating insurance markets,’ the Bank's tew policy for the Third World sounds suspiciously like the health care
model of the United States. It argues that private health care for individuals gives more choice and satisfaction and
is mon- efficient. But there is little evidence to support this claim. The US health system, dominated by a strong
profit-hungry private sector, is by far the must expensive in the world, yet US health statistics are the worst among
the Northern industrialized nations. Indeed some US health indicators are worse than those of certain Third World
countries. Most striking is Die extreme inequity of the US health system Washington DC, with its large low-income
population, has poorer child and maternal mortality rates than Jamaica. ' Several US inner cities have immunization
rates as low as 10%, and for the last several years deaths from measles in (he US have been increasing.18
The commerdal medical establishment and some large NGOs have celetsated the World Bank’s Investment in Health
strategy as a ’breakthrough’ toward universal, more cost-efficient health care. But most health rights activists see
the report as a masterpiece of disinformation, with dangerous implications. They fear the Bank will impose its
recomrnerelations on those poor countries that can least afford them. With its enormous money-lending capacity,
the Bank can force poor countries to accept its blueprint by tying It to loans, as it has done with structural
adjustment. In addition, the Bank states that it will encourage the donor community "to assist by financing the
transition costs, especially in low-income countries." So beware!
A call for organized protest of the World Bank’s intrusion into health policy making
It is an ominous sign when a giant financial institution with such strong ties to big government and big business
bullies its way into the field of health care Yet according to the British medical journal. Latest, the World Bank
is now moving into first place as tire gjcbal agency most influencing health policy, leaving the W’orld Health
Organization in a weaker second place.
Despite all its rhetoric about alleviation of poverty, strengthening of households, and more equitable and efficient
health care, the central function of the World Bank remains the same: to draw the rulers and governments of weaker
states into a global economy dominated by large, multinational corporations. Its loan programs, development
priorities, and adjustment policies have deepened inequalities and contributed to the perpetuation of poverty, ill
health, and deteriorating living conditions fcr at least one billion human beings.
In various parts of the world, concerned groups are attempting to engender a broad-based protest of the pernicious
policies of the World Bank and IMF. Health Action International has put together a packet of writings from a wide
variety of sources, criticizing the 1993 World Development Report and alerting health activists to oppose it.
1 To become better informed about th* full range of objections to the Report and the World Bank's controversial
prescription for health, you can write to. Health Action International- Europe, Jacob van Lennepkade 334 T, 1053
NJ Amsterdam, The Netherlands
For more information on the "50 Years is Enough" campaign, the groups involved, and a calendar of events, you
can contact: The Bank Information Center, 2025 I Street, NW, Suite 522, Washington, DC 20006. tel (202) 466-
10
Covering a broader critical analysis, "50 Years Is Enough" is an International coalition organized around the 50th
anniversary of the World Bank and IMF. Involving scores of environment, development, religious, labor, student,
and health groups, it represents an unprecedented worldwide movement to reform these International Financial
Institutions. At the same time, many groups and networks around the globe are working on health and development
issues from a grassroots perspective, trying to listen and respond to what people want. They are attempting to create
broad public awareness of our current global crises, and to organize a groundswell of pressure from below oo the
world's policy making bodies. Two such grassroots coalitions based in the South are the Third World Network based
in Malaysia, and the International People's Health Council, based in Nicaragua
It is urgent that all of us concerned with be health and rights of disadvantaged people become familiar with the
World Bank's Investing in Health Report. We must speak out clearly about the harm its policies are likely to do.
and clarify whose interests those policies serve. New communications methods are needed to alert ordinary people
to far-reaching concerns, and to counter massive disinformation, which has become tl>e most effective strategy of
social control. Never has the need been greater for a coordinated global effort to demand that world leaders and
policy makers be accountable to humanity.
8191; fax. (202) 466-8189
For a compreheniive bit of groupi around the world working on development iiiues from a gmirooti perapective,
you cm coniult the International Directory of Non-Oov«mmmt Organization!, compiled by WorldWua, 401 San
Miguel Way, Sacramento, CA 95819, USA.
11
Endnotes
I.
Brown LR, editor. Stale of the World, 1994. New York; London W. W. Notion. Foreword.
2.
Grant JP. State of the World's Children, Z994,UNICEF, p. 66.
3. The term "disease palaces" was first used by primary health care pioneer David Morley in his classic book
"Paediatric Priorities in Developing Countries."
4.
Werner D, Bower B. Helping Health Workers I,earn. Hesperian Foundation. 1982. p. 18-7.
5. Grant JP. Stale of the World's Children, 1994,UNICEF, p. 80; Brown LR, editor. State of the World, 1990,
Dinning, AB. "Ending Poverty", p. 138.
6.
Grant JP. State of the World's Children, 1994,UNICEF, p. 3,6,7.
7.
Grant JP. Stale of the World's Children, .’994.WICEP, p. 6.
8.
Petras, James. “Cultural imperialism in tie late 20th century." Third World Resurgence. No. 37, 1/ 94. P. 30
9.
Costello A, Watson P, Woodward D. Human Face or Facade? Adjustment and the Health of Mothers and Children.
1944. London. Institute of Child Health.
10. Danaher K, editor. 50 Y ears is Enough: the case against the World Bank and Internationa! Monetary Fund. South
End Press. Boston MA. 1994.
11. Bruin J, Cicada G, eds, Justice Denied! Human rights and the international financial institutions. 1994. Woman's
League for Peace and Freedom, Geneva; and International Institute for Human Rights, Katmandu Nepal, p.3.
12 Comia G, Jolly R, Stewart F, eds, 1987, Adjustment with a Human Face, Oxford, Clarendon Press for UNICEF.
13, Moses S, Manji F, Bradley JE, Nagelkerke NJ, Malisa MA, Plummer PA. "Impact of user fees on attendance
at a referral centre for sexually transmitted diseases In Kenya." Lancet 1992; 340463-6.
14. The World Bank, World Development Report 1993— Investing in Health, Oxford University Press for the World
Bank.
15. Ruck N, Stefanini A. "World Development Report 1993 - 'Investing in Health'—Old Wire in New Bottles?" [ftill
reference needed)
16. Legge D. "Investing in the Shaping of World Health Policy," Prepared for the A1DAB, NCEPH and PHA
workshop (Canberra, Australia, Aug. 31. 1993) to discuss the World Bank's 16th World Developtrcnt Report.
Im-e sting in Health.
17.
Werner D, "Health for No One by the Year 2000," Third World Resurgence, Ho. 21, 1992.
18.
Grant JP. Stale qf the World's Children, 2994. UNICEF, p. 46.
19.
Editorial. The LancetNd 342, July 10, 1993, p 63. 64 and 105 & 106.
12
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