«ANSA Alternatives to Neo-liberalism in Southern Africa The search for Sustainable human development in Southern Africa Editors: Godfrey Kanyenze, ...»
The contribution of values and social action to the production of health gains in the region has been somewhat underplayed, and in more recent years has been replaced by a bias towards technical argument and evidence. This carries implicit values and can be used to weaken social action. While the provision of health services in the Southern Africa region had its roots in colonial systems and the domain of charities, its character underwent a radical transformation in anti-colonial struggles based on popular movements that organised around rights to land, to education, to organise, to work, to housing, the right to be free from brutality etc. In almost every case, the right to health and to access to health services was a fundamental demand of the popular movements (EQUINET SC 2000). At independence, governments responded to the popular demand for the state to accept its responsibility for both the provision of health services and for some of the wider inputs to health, such as safe living environments. State and public
• Redistributed health budgets towards prevention • Improved access to and quality of rural, informal urban and primary care infrastructures and services • Deployed and oriented health personnel towards major healthcare problems • Supported personnel with adequate resource inputs • Ensured fairer distribution of resources between the public and private sector providers • Invested in community-based healthcare • Encouraged the effective use of services by improving dissemination of information on prevention and early management of illness • Removed cost barriers to primary care services at point of use (EQUINET SC 1998, 2000).
3. Alma Ata: from primary healthcare for everyone to selective primary healthcare These government policies were backed by policies that also enhanced the public provision of education, female literacy, safe water and sanitation, contributed to health improvements and improved effective uptake of health services. In some countries policy measures were also introduced to improve access to housing, employment and improved incomes (EQUINET SC 1998, 2000).
These were backed by an important global policy movement that led to and followed the Alma Ata Declaration on Primary Healthcare and Health for All. "Health for all" called for the provision of primary healthcare for everyone, irrespective of the ability to pay for it. The declaration, which was signed by all WHO member states, endorsed primary healthcare to at least include health education, the promotion of food supply and proper nutrition, an adequate supply of safe water and basic sanitation, maternal and child healthcare (including family planning), immunisation against major infectious diseases, prevention and control of local endemic diseases, appropriate treatment of common diseases and the provision of essential drugs. Developed countries undertook to guarantee the health of the poor. The defeat of fascism required the complete support of people.
The emergence of a strong socialist camp also made it essential for these governments to win over their workers. The vision of PHC was modelled after the successful grassroots community-based health programmes in various countries, as well as the work of "barefoot doctors" in China. It called for strong community participation in all phases, from planning and implementation to evaluation.
The basic values in the "health for all" and PHC movement were not new.
Health was recognised to be a human right and an intrinsic good.
The health policy was recognised as a reflection of the value systems of a society. In particular, the experience of the industrialisation processes in the north were clear: Advancing health depended on state intervention, supported by rising investments in public health systems, and organised on the basis of equity, solidarity and universality within largely publicly organised and provided services and activities. The early 1900s had also made it clear that access to food, safe water and living environments, decent work, education, sexual autonomy and social cohesion made a greater contribution to health than medical technology.
Internationally, when countries faced major health challenges, they responded by having the state and public sector invest more in health.
The most famous example of this was the National Health Service in Europe that was funded in the early and mid 1990s by the comprehensive tax or social insurance. These services backed public health measures that were introduced during the industrial revolution to deal with disease epidemics in the rapidly urbanising population, particularly the public provision of safe water, sanitation, immunisation and the promotion of improved diets (Mackintosh and Koivusalo 2004, Mehrotra 2004). 34.
The PHC movement went further however. It argued that health is a consequence of the organisation and distribution of social, political and economic resources. Health is a reflection of the power relations within society and thus a consequence of the power and autonomy over the resources for health.
Because it called for the full participation of the underprivileged along with an equitable economic order, the ruling class considered it subversive.
UNICEF, buckling under accusations by its biggest funder (the US government) that it was becoming "too political", endorsed a disembowelled version of PHC called Selective Primary Healthcare.
Selective PHC argued for a package of technical interventions at local level that could be funded without major transformations of resources for health or health systems, and thus without making significant changes to economies or building a more equitable social order. It preserved the status quo of existing wealth and power and left the social groups and Significant evidence on the role of rising investment in public health sectors organised on principles of solidarity and universality in building health systems and producing health gains in wealthy countries is led in papers by Mackintosh and Koivusalo and by Mehrotra. Although there has been propaganda to persuade that health gains were built on liberal choice around private providers, the facts and evidence dispute this. In fact increased investment in private providers at national level is argued to be a punishment of the poor, not a choice of the wealthy.
community organisations pushing for wider change without the powerful UN allies that they thought they had in the Alma Ata declaration35.
Within Southern Africa at the same time as governments intervened to ensure universal healthcare, they also began to transform the very essence of the health movement that these systems were based on. The liberation movement's concept of health drew from a mix of a struggle for rights and popular participation linked to the struggle for the wealth and power to realise these rights. Post independence health systems were increasingly controlled by medical and technical interests, and organised communities and health promotion around technical problems and interventions that required technicians and experts. This was compounded when the state took on a centralising and controlling role as the "sole developer" and "sole unifier" of society. While these trends may be explained by the pressures and threats that confronted nationalism, in the social sector it meant that "development" was a benefit to be delivered by the state, and social movements or grassroots groups were seen as irrelevant or to be controlled unless they were under state or political patronage. Community participation, a key element in all post independence health policies and gains in the region, was generally cast as mobilisation to effect health programmes planned and financed at higher, often central levels, and was more dependent on state than on self organisation (EQUINET SC 1998, 2000). When the health services showed positive growth, instead of this being a source of tension, it led to some demobilisation of autonomous community organisations as people transferred authority for action to the state.
4. Free market ideology, World Bank and health
Comprehensive PHC and global protection of universality, solidarity and equity as a basis for health policy was dealt its most severe blow when the World Bank took on the restructuring of health systems in line with its neo-liberal free-market ideology. The World Bank structural adjustment programmes introduced from the early 1980s onwards had a clear and devastating effect on health by undermining the structural factors that produce good health (jobs, incomes, food security, shelter etc). These policies increased indebtedness and the rate of exploitation of low-income communities across all countries and shifted wealth from productive to speculative financial sectors where boom and bust became the order of the day. Many countries opened export-processing zones (EPZs) to attract The Website of the People's Health Movement has a large number of papers that inform on PHC, global health policy changes and the political and economic factors that underlie these changes. See for example http://www.phmovement.org/pubs/index.html#Issue%20Papers foreign investment, driving down their own labour costs and forgoing tax revenues. They led to a significant increase in casual, poorly paid and insecure forms of labour and increased poverty in already poor countries36.
In the 1990s the World Bank extended its reach to the health sector itself.
While the previous effects of World Bank policies on health had been to reduce funding to the health sector and undermine the resource capacities to sustain essential drugs and primary healthcare policies, in 1993 the World Bank published its World Development Report, titled "Investing in Health." and challenged the values and principles that had underpinned health systems in the north through their own development and that had been extended globally through the Alma Ata declaration and "health for all". While presented as a technical evidence-based argument, the World Bank policies in health were deeply driven by values and ideologies, and were based on little evidence of successful application in the real situation of developing countries.
Health and healthcare was argued to be a product of technical, generally biomedical knowledge and an outcome of medical intervention. The role of the state in healthcare was questioned, and a more "efficient" role proposed for the state as a regulator and moderator of services, and not a direct provider. Health services were seen to be better organised as a mix of largely private discrete services with residual public sector prevention interventions, which was often vertical and disease focused. These segmented health systems, which were mainly along the lines of the purchasing power of communities and patients, with targeted "propoor" strategies and exemption mechanisms for those who were judged to be unable to pay.
This led to two major shifts in health. Health was no longer a right to be secured through community and state action, but a commodity to be purchased primarily through the market, with some residual "public goods" role for the state.
Decisions on health policies and interventions would no longer be grounded on values of solidarity, universality or equity, but on considerations of the efficiency, and particularly the cost efficiency, of specific technical interventions.
See for example Rao and Loewenson (for the political economy underlying the structural adjustment policies in health http://www.phmovement.org/about/background1.html Efficiency-driven perspectives dominated international health policy prescriptions and focused attention away from the interface of services with communities and health systems as a whole. This led to the development of approaches aimed at the cost effective rationing of scarce resources for healthcare and of management and measurement tools to support these approaches. Such reforms may, in fact, have done little to enhance efficiency, even while there is evidence that they worsened the quality of or equity in healthcare.
While these strategies were deeply unpopular amongst health professionals as well, the Bank consolidated its hold over health policy
through a range of measures:
• The Bank took over WHO's role as world leader in health policy powered by money. The World Bank's budget for "health" grew to three times that of WHO's total budget.
• As public budgets and tax-based financing for health fell under wider SAP reforms, greater attention was given to resource mobilisation and efficiency, opening the way for arguments for cost recovery, and management reforms while drawing attention from the significant under funding of the sector.
• Ministries of Finance, the Bank's traditional counterpart, took a more decisive control over health policy as fiscal policies became determinant of a wide range of issues affecting health (including human resource planning, budget levels, etc).
• The growing gap between services and communities and the weakening of public health services depressed public confidence in and the defence of the public health system.
• Technical personnel within the state at higher levels built closer and more frequent relationships with official "aid agencies" and Bank personnel than with their own popular organisations.
While some constituent civic organisations tried to resist and confront these changes, others came in to fill the gaps in service provision created by the state withdrawal or by falling access due to commercialisation, gaining resources and visibility in the process. There were many winners in this process who were prepared to defend and sustain it. Many were articulate and had profile. The losers were generally the poor and majority, who were increasingly marginalised from services and those state health sectors and health professionals who were defending public health values, were increasingly marginalised from the corridors of power.
While many trade unions actively resisted these structural adjustment measures, their members were increasingly forced into becoming users of private services by market reforms. Some unions were pressured to bring demands for employer cover for medical insurance and healthcare to union negotiations. As workers struggled to deal with escalating costs of care, health worker unions organised around their own falling real wages.
Meanwhile the public health sector was being eroded and segmented by falling funding and privatisation.
5. Globalising neo-liberalism in health