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Amitava
Guha The Lancet in July,
1993, reported that the World Bank (WB) is now moving
into first place as the global agency most influencing
health policy. Since 1980 the World Bank’s
involvement in heath had faced bitter criticism but this
could not change its basic approach towards the health
sector. It was observed that the more debt dependency
developed in third world countries, the more they became
bankrupt. This debt crisis, as stated by UNICEF, had
following effect - "It is children who have paid the
heaviest price for the developing world’s debts.
Fragmentary evidence …has shown a picture of rising
malnutrition, and in some cases rising child deaths, in
some of the most heavily indebted countries of Africa and
Latin America". It is obvious that countries which
have no capacity to meet debt services first cut their
investment on country’s social security measures.
With one of the world’s highest foreign debts of
over $100 billion, Brazil's interest payments exceed $30
million a day. Since the late 1980s Brazil’s infant
mortality rate had been improving. Now the country has a
disturbingly high under-five child mortality rate - 63
per 1000.
Policy Changes -
Major Condition Of Debt
WB and International Monetary
Fund (IMF) had espoused Structural Adjustment Programme
(SAP) with debt for the third world countries. In order
to meet the requirements of debt, SAP dictates a number
of measures in policy decisions in these countries.
- It directs cuts in public spending
on health, education and other social services.
- Removal of subsidies and lifting
of price controls on food and other basic
commodities.
- Freezing wages.
- Shifting of production of food and
goods for domestic consumption to production for
imports.
- Relaxation of regulation and tax
breaks to attract foreign investors.
- Privatization of public services
and state enterprises.
- Devaluation of currency.
World Bank’s policy of investment
in disease specific or crisis specific areas was changed
to sector-wide approach. Argument in favor of the change
was that the previous mechanism had a fragmented approach
to health care delivery system with projects often being
duplicated and both donor and client’s time being
consumed by project assessment. Critics of sector-wide
approach say that "rather than selecting individual
projects, internal agencies contribute to the funding of
the entire sector. In exchange for giving up the right to
select projects according to their own priorities, donors
gain a voice in the process of developing national health
policies, and in decisions about how not only external
but also domestic resources are allocated". Even WB
employees are critical of this approach. As quoted in the
British Medical Journal (BMJ) of April 10, 1999, the
employees commented that ‘The debate pitting the
value of the sector-wide approach against the merits of
vertical projects is false dichotomy. In fact, most bank
projects deal with health policy and policy change".
Experience in the third world shows that WB has directly
interfered in the policies of many countries and forced
them to change according to deigns of SAP to make them
eligible for receiving debts. Important conditions put by
the bank in its new investment proposals on health are -
a) payment of cost sharing charges by consumers of public
services, especially for drugs and health care, with
different levels to protect the poor; b) incentives to
private health insurance as a preferential mechanism to
increase coverage, while limiting mandatory insurance to
cover 'catastrophic risks'; c) encouragement of the
private sector, either for profit or non-profit, to
provide the largest possible amount of health care while
the government focuses on prevention; d) support
decentralization in planning, budgeting and management of
public health services (World Health Organization, 1998).
User Charges
Since the third world countries
are unable to meet or maintain health care costs, one way
raise funds have been introduction of user charges for
using the public institutions. Health economists have
criticized introduction of user charges for causing
health disasters. "Increase in maternal mortality
and in the incidence of communicable diseases such as
diphtheria and tuberculosis have been attributed to such
policies. An article by a WHO health economist published
in BMJ stated that, "as an instrument of health and
policy, user fees have proved to be blunt and of limited
success and to have potentially serious side effects in
terms of equity." The Lancet commented that the
introduction of user fees, along with other measures of
SAP, might be contributing to the rapid spread of AIDS in
Africa. In Ghana, health care utilization decreased by
50% when cost recovery was introduced. When in 1981 China
introduced user payment for tuberculosis treatment,
between 1 and 1.5 million cases of TB remained untreated,
leading to 10 million additional persons infected. Many
of the 3 million deaths from TB in China during the 1980s
might have been prevented.
Misconceived Policy
Of DALY
The World Bank in its report
‘Investing in Health" postulated DALY
(Disability Adjusted Life Years) for determining priority
in health care investment. It suggests different values
to years of life lost at different ages. The value for
each year of life rises from zero at birth to peak at age
25 and then decline gradually with increasing age. Very
young, elderly and disabled are less likely to contribute
to society in economic terms; hence fewer DALYs can be
saved by health investments which address their ills.
According to WB, leukemia treatment is not cost
effective, achieving 1 DALY for every US$ 1000 spent,
while vitamin A supplementation achieves 1 DALY for just
under US$ 1. By the same logic it is stated that
overwhelming majority of nursing care would be judged to
be of little or no value. This concept becomes most
dangerous when it is used to prioritize health care
allocation of scare resources. BMJ mentioned that DALYs
are being increasingly used for health sector planning,
they are in fact an inequitable measure of ill health and
as such an inappropriate and unfair criterion for
resource allocation.
Impact On Health By
Policy Intervention
Policy intervention has become
a serious phenomenon in the third world countries. Not
only through SAP, but with several other very large scale
treaties being established, constraints are now being
imposed on these poor countries that include forced
policy changes on patents, services, investment,
agriculture, etc. Change of policy in almost every vital
area is posing serious threat to sustainability. Even WB
employees have admitted that sustainability has remained
neglected in the past, and, although it was addressed as
priority in the 1997 sector strategy document, it remains
unclear how this objective will be achieved. The extent
to which these conditions of the World Bank, the
compulsions of joining international treaties and direct
intervention of the developed countries has created
miserable conditions, can be understood from a press
release of Health Action International (HAI). HAI has
informed that trade pressure against Thailand by USA led
the country to give up its attempt to produce the
anti-AIDS combination drug (azidothymidine-didanosine or
AZT-ddl) at an affordable price. Though invented in a
public institution of USA, ddl was patented by
Bristol-Myers Squibb bringing the cost of monthly therapy
to US$ 165, whereas the Thai Government has frozen daily
minimum wage of manual workers to US$ 4.50 following SAP.
The question of sustainability becomes more important
when we find that 26 out of over 33 million people
infected with the AIDS-virus live in Sub-Saharan Africa
and have no access to anti-retroviral drugs. In case of
TB, most of the 100,000 people in developing countries
suffering from multi-drug resistance strains are unable
to afford new standard combination treatment which is
priced at approximately US$ 15,000 per course.
We are yet to know if the World Bank
has any answer to undo this situation.
References
- Lobo F, Velasquez G, editors.
Medicines and The New Economic Environment.
Madrid: WHO & University Carlos III De
Madrid; 1998.
- Warner D, Sanders D. The Politics
of Primary Health Care and Child Survival. Indian
edition. Calcutta: Baulmon Prakashan; 1998.
- British Medical Journal,
successive issues from April 20, 1999.
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