Human needs versus human greed
There is a close link between health and self-determination, both personal and collective. This has always been true. But in today’s shrinking, endangered world, self-determination for the disempowered majority has become increasingly difficult.
There was a time when people in an isolated village, by learning and working together, by taking collective action to resolve their biggest health problems, could substantially improve the overall level of health. The key determinants of sickness and health were local. They were largely manageable through local organized effort. By working together to change their situation, people, to some extent, had control over their health, their lives and their destinies.
But in today’s world - to paraphrase John Donne - "no person, community and even nation is an island unto itself". The well-being of people, even in the remotest village, is drastically affected by decisions made by wealthy businessmen and powerful policy-makers, bankers, and health and development planners in Washington, Geneva, and other centres of global power.
In the last decade or so, faster than ever, wealth and power began to be concentrated into fewer and fewer hands. Today the world has 358 billionaires who have earnings equal to those of the poorest half of humanity. The development model which pursues economic growth of the already rich, regardless of human and environment costs, has reversed generations of progress toward a social order that had begun to envisage "Health for All" as a basic human right.

Westerm medicine since colonial times
In the days of colonialism the western medical model was first introduced into the South to serve the dominating white colonists. The local peasantry and working class were mostly excluded. In the 18th century, the initiation of basic health services for the so-called "natives" was introduced not because health was considered a human right, but because the ruling class discovered that healthy workers produce more. (This is much the same logic that the World Bank has reintroduced in the 1990s).
Gradually, in the 19th century, a social consciousness evolved where it was considered that society collectively had a responsibility to assure that the basic needs of all people were met. With the formation of the United Nations and the World Health Organization in the 1940s, health - and basic health care - were declared basic human rights.

But in poor countries in the South, as well as pockets of poverty in the North, levels of health remained abysmal. Health services were largely limited to extravagant urban "disease palaces", inaccessible both in distance and cost to the rural and poor majority.

But more than the lack of health services, the continuing high rates of morbidity and mortality, especially among children and women, were caused by poverty, powerlessness and cruel exploitation of the poor by the rich.

The growth of community-based health initiatives
From the 1950s, after World War II, through the 1970s, in a number of poor countries, the enormous unmet health needs of vast numbers of people gave rise to a variety of grassroots, popular alternatives to the elitist Western medical model. A lot of these movements grew out of, or helped engender, popular struggles of liberation from cruelly unjust dictatorships and military regimes. They ranged from the Community-Based Health Care Movement in the Philippines and the brigadistas e salud in Nicaragua to the barefoot doctors in China.
These people-centred health initiatives - which often did far more to meet the health needs of the poor than did the established Western medical system, whether government or private - had a number of features in common:

• Frontline of health services provided by modestly-trained "community health workers" (who were selected by and accountable to the local community). (Doctors at best played a secondary back-up role: on tap and not on top).
• Strong emphasis on preventive care and health education.
• Strong community participation and collective community action.
• Efforts to analyze and combat the underlying social and political causes of poor health: low wages, unemployment, inequitable distribution of land, resources, and public services.
• Top priority to defend the interests of the neediest and most vulnerable groups.
• Respect for the best of indigenous agriculture and traditional forms of healing.

The Alma Ata Declaration and "Health for All"
In 1978 the World Health Organization and the UNICEF held a global meeting in Alma Ata, Russia, at which leaders from the world’s nations signed the Alma Ata Declaration. They committed themselves to working toward "Health for All by the Year 2000", through a potentially revolutionary strategy called "Primary Health Care". PHC was a comprehensive approach which sought a balance between curative, preventive, promotive and rehabilitative actions. It placed strong emphasis on community participation not only in planning and controlling health services, but also in taking organized action to overcome the social, economic and political obstacles to health. Most remarkably, the Declaration called for a new economic order based on equity, to assure that all people’s basic needs could be met.
Sadly, as we approach the year 2000, the goal of Health for All appears to be growing more distant. In the late 80s and 90s much of the progress of earlier decades has slowed down and in some countries it has been reversed. Some say that Primary Health Care has failed. Others say that it has never been tried. It has become clear that the concept of Primary Health Care, with its emphasis on strong popular participation in decisions determining health, and a new economic order based on meeting all people’s basic needs was a threat to the ruling elite, both in the North and South. Over the years, various high-power moves have been made to disembowel PHC of its people-empowering, social revolutionary potential.

Assaults on Primary Health Care

There are three major assaults on Primary Health Care:-

1. Selective Primary Health Care, introduced in the late 1970s.
2. Structural adjustment and user-financing, introduced in the 1980s.
3. The World Bank’s takeover of the Third World’s health care policy planning in the 1990s.

Selective Primary Health Care
It was argued that a comprehensive approach which called for fighting poverty, equalizing society, strong participation - would be too costly and it was suggested that if changes in health were going to take place, we had to focus on a few specific areas, so the concept of GOBI was created with a focus on Growth-monitoring, Oral rehydration therapy, Breast-feeding, and Immunization. And UNICEF backed this up with the so-called child survival revolution. Because this destroyed the revolutionary or change-oriented concept or comprehensive approach, some people called it the revolution that isn’t.
The comprehensive primary health care aimed at health for all in the broad sense of physical, mental and social health, whereas selective primary health care was focusing not so much on health for all but on improving survival statistics for special groups like children. This was unfortunate to make the approach to health care so technological and so selective because historically the major improvements in health that have taken place in our healthier societies were not because of technological, medical interventions but because of improvements in living conditions which came about through organizations of working people for their basic rights. In England, on the top, Tuberculosis was largely brought under control before the introduction of antibiotics and BCG vaccine because of improved living standards and living conditions. In the lower picture we see a similar decline in the diseases of child birth before the invention of antibiotics and immunization. If we are really going to the roots of this problem, we really have to think in terms of improving living conditions for all people and not just a bio-medical intervention.

The Structural Adjustment Programme (SAP)
The second assault on primary health care was that of the structural adjustment programmes (SAPs) introduced by the World Bank and the International Monetary Fund. They were mainly introduced in order to keep governments of poor countries which were in economic crisis largely because of their heavy debt burden. They owed so much money to the banks in the North that their economies were floundering, so the World Bank and IMF stepped in to make sure that the governments of poor countries kept paying their interests to the Northern Banks.
Structural adjustments consisted of a number of measures to free up money of the government so that they could pay their high interests. These included cutbacks in public spending, privatization of government enterprises, freezing of wages, and freeing of prices, increase in production for export rather than for local consumption which, of course, made food supply less available, pushing prices up even when wages were kept down, which made it much harder for poor people to feed their children, and reducing tariffs and regulations to attract foreign capital and trade.
Finally reducing government deficits by charging user-fees for social services including welfare... Privatisation of health care makes poor people pay for services which were still provided by government, to make costs lower for government so government can pay more to the Northern banks for their interests. The World Bank argues that its SAPs have not damaged poor countries or have not caused unnecessary hardships or increased poverty, and they use statistics like this showing that the improvements over a long range of time from 1965 to 1990 ... in the infant mortality rate ... from 1965 to 1990. However, if we look at some of the actual countries where SAP have been introduced, rather than just showing 1965 and 1990, in many countries health was improving substantially, child mortality was declining, as in Ghana until SAPs were introduced and then child mortality increased again, and this has happened in many countries.
There has been a reversal in the gains in child survival and in quality of life and standard of living with these very cruel SAPs which have hit the poor the hardest. One of the SAP policies is to charge people with the cost of services. Over many, many years, civilization has evolved to the point where we were beginning to relate in countries like families do. The people who were more fortunate helping those who are less fortunate, to a process of progressive taxation, where the rich pay more taxes to help the poor meet their basic needs. This has been rolled back. This process of civilizing ourselves have been reversed through the modern economic policies where you pay for everything. So you see what happened in Ghana again where user charges were introduced in primary health posts, the utilization rate dropped enormously. Children were not getting the health care they needed and this helps explain the increase in child mortality. Yet the World Bank says that Ghana is a success story. Its economy has recovered. But at what cost to children’s lives? They don’t think about that. They think about the dollar figures, the rich are getting richer - that’s what matters.

World Bank's takeover of Third World Health Policy Planning
The third assault on primary health care was the World Bank’s efforts to takeover health policy planning of the Third World. "Investing in Health", the World Bank Report, in 1993 comes up with its position. It is actually a masterpiece in disinformation, it looks progressive while it sustains a lot of the conservative structural adjustment policies which have tended to concentrate wealth into fewer and fewer hands. There are many conservative aspects in the World Bank Report. I don’t want to say that it is all bad, it isn’t.. it includes a variety of things and I won’t go over them right now.
However, if we look at its three-pronged policy for health reform, we can see that it sounds fairly good. "Fostering an environment for households to improve health". How wonderful. "Improve government spending in health". Yes, it makes sense. "Promote diversity and competition in the promotion of health services" Well, may be.
But when you analyze, when you read the fine print in the Report, you find out that "fostering an environment for households to improve health" means that households should pay for their own health services and that household income should improve. But again through the old philosophy of invest in the rich and hope that some of it will trickle down to the poor. Same old story. Improve government spending on health boils down again to a new version of selective primary health care.
Promote diversity and competition in the promotion of health services is largely promoting a model of health care with privatization of medical services and a system which is very similar to the health system in the United States which is the most expensive health system in the world and yet in the US the health levels are the poorest of the wealthy countries. So it doesn’t make sense.
The World Bank, in order to decide where governments should put their money in health care, has invented a system called DALY, or disability adjusted life years. Basically they rank human individuals according to how much they can contribute to the economy. By the economy they mean, making the rich richer basically. And so, in the upper chart, babies, small children have very low value because they contribute nothing, they take from the economy initially. At 20-30 years, persons have the highest value, they are working hard, and the elderly, again, lose value. This means that for children, for the elderly, and especially for disabled people they don’t have value and they don’t deserve public spending for their health care. It’s a very cruel and dehumanizing interpretation of health care.
In fact the monetarised approach to health where people are viewed and turned into producers of money sort of sums up the World Bank’s position... The result has been what we discussed already. That health is deteriorating, health is getting worse for billions of people in the world. A gap is growing between rich and poor, very fast, today 60 billion dollars flow from the poor countries to the rich, largely in payoffs for loans made decades back. In the meantime, poor people in the world don’t get enough to eat although there is plenty of food to feed everybody. It is not the total supply, it is in distribution where the problem lies.
Here you see the distribution of wealth concentrated in the richest 20% and the difference is increas ing. The World Bank is supposed to be a development bank, although in 1984 it was loaning more money than it took back in interest, today the World Bank itself is taking much more money back from the poor countries than it loans them. So it is becoming one of the major exploiters of the poor countries, increasing this problem.

Although the World Bank says its role is to do away with the foreign debt in poor countries, the poor countries’ debt continues to rise.

There are alternative approaches to development which is focused more on social development than on economic growth. The Rockefeller Foundation 1985 did a study called "Good Health at Low Cost" looking at Sri Lanka, Costa Rica, China, and Kerala State in India, countries which have achieved health statistics equivalent to the rich countries of the world - low child mortality, long life expectancy, but at very low cost for very poor countries. And they found certain things in common in these countries, although the political spectrum was from left to right - that was not in common, but they found a strong political and social commitment to equity, a commitment to education to all people, particularly primary levels - equitable distribution of health care for all the population including the rural areas. And finally, I think, most importantly, assurance of an adequate calorie intake for all people - or enough to eat for everybody. And doing this in a way that maintained the small farmers’ traditional agriculture. Well, this is a completely different model of development not being pushed by the power in the world today and the World Bank, and it makes a lot more sense. Even though these four countries are now beginning to lose their gains as they shift toward a market-growth oriented economy.
In conclusion: Martin Luther King said that "history is the long and tragic story of the fact that privileged groups seldom give up their privileges voluntarily". So what we are talking about is a grassroots movement to pressure the powers that be to respond to the needs of the great majority of the people.
* Reproduced from the Asian Health Institute Newsletter No. 53, December, 1966).

[top] [index]