People's Democracy

Twenty Five Years After Alma Ata

Amit Sen Gupta

THE next year is going to be the 25 anniversary of the Alma Ata Declaration. The Alma Ata Declaration of 1978 was seen at that time as a watershed in the understanding regarding public health. The declaration, adopted by almost all the countries of the world had asserted the necessity for the State to provide accessible, affordable and comprehensive health care services to all the people. Unfortunately, in the decades following the declaration, neo-liberal economics supplanted this view across the globe. Within less than a decade of the adoption of the declaration, the World Health Organisation proposed actions that undermined the basic premise of the Alma Ata Declaration. Since then the WHO itself has been superceded by the World Bank and the IMF as the key players in formulation of policies in the health sector.

DECIMATION OF HEALTH INFRASTRUCTURE

In the last two decades the infamous Structural Adjustment Policies, thrust upon developing nations by the IMF have decimated health care facilities in almost all developing countries. Specifically, they had the following consequences for the health sector:

i. A cut in the welfare investment, leading to gradual dismantling of the public health services.

     ii.            Introduction of service charges in public institutions, which has now made the services inaccessible to the poor.

   iii.            Handing over the responsibility of health service to the private sector and undermining the rationality of public health. The private sector on the other hand focused only on curative care. India for instance, has been forced to reduce its public health expenditure in health and to recover the cost of health services from its users by international banks.

   iv.            The voluntary sector, which has also stepped in to provide health services is forced to concentrate and prioritise only those areas where international aid is made available - like AIDS, population control, etc.

These "fundamentals" were more sharply focused upon in 1987 by the World Bank document titled "Financing Health Services in Developing countries" The document recommended that developing countries should:

1) Increase amounts paid by patients.

2) Develop private health insurance mechanisms (this requires dismantling of state supported health services as if free or low cost health care is available there is little interest in private insurance).

3) Expand the participation of the private sector.

4) Decentralise government health care services (not real decentralisation but an euphemism for "rolling back" of state responsibility and passing on the burden to local communities).

These recommendations were further "fine-tuned" and reiterated by the Bank's World Development Report, 1993 titled "Investing in Health". This document represents the Bank's major foray into health policy formulation. Today the Bank is the decisive voice in this regard, and organisations such as the WHO and UNICEF have been reduced to playing the role of "drum beaters" of the Bank. As a Bank economist candidly reflected: "Policy lending is where the bank really has power - I mean brute force. When countries really have their backs against the wall, they can be pushed into reforming things at a broad policy level (which) normally, in the context of projects, they can't. The health sector can be caught up in this issue of conditionality"

WIDESPREAD CONSEQUENCES

In almost every developing country, these prescriptions have been avidly lapped up. In Philippines health expenditure fell from 3.45 per cent of GDP in 1985 to 2 per cent in 1993; and in Mexico from 4.7 per cent of GDP to 2.7 per cent in the decade of the 80s. Even developing countries with a strong tradition of providing comprehensive welfare benefits to its people were not spared (with the exception of Cuba). In China health expenditure is reported to have fallen to 1 per cent of GDP and 1.5 million TB cases are believed to have been left untreated since the country introduced mechanisms for cost recovery. In Vietnam the number of villages with clinics and maternity centres fell from 93.1 per cent to 75 per cent.

These prescriptions are a major contributory factor to the disruption of the rural primary health care system in India. In GDP terms health expenditure in the country (already one of the lowest in the world) has declined from 1.3 per cent in 1990 to 0.9 per cent in 1999. While central budgetary allocation has remained stagnant at 1.3 per cent of total outlay, the budgetary allocation to health in state budgets (which account for over 70 per cent of total health care expenditure of the country) has fallen in this period from 7.0 per cent to 5.5 per cent. This is a direct consequence of the squeeze imposed on the finances of the states by the economic liberalisation policies. In reaction to this, desperate state governments are queuing up in front of the World Bank to receive Bank aided projects. This is proving even more disastrous as these projects impose strict conditionalities like cost recovery.

MACROECONOMIC COMMISSION ON HEALTH

The World Health Organisation, long a silent spectator to the process whereby the Bank had usurped its functions, attempted to make amends by setting up a Commission on Macroeconomics and Health. The Commission's Report was unveiled by Gro Brundlandt in December 2001. The CMH has been touted as the WHO's endeavour to enage the best economic minds of the world in producing a vision paper on health in a globalised world. Appropriately, the Commission was chaired by Jeffrey Sachs, described by the New York Times as "probably the most important economist in the world". What we have before us, as a result of this exercise, is an unabashed attempt by the WHO to speak the language of the Bank. The ideological takeover of the WHO is, thus, complete.

The Report in its introduction says, "With globalization on trial as never before, the world must succeed in achieving its solemn commitments to reduce poverty and improve health". In other words, poverty reduction and health improvement are goals that need to be achieved in order to rescue globalisation from the dock!

While this is not the place to go into a detailed critique of the Commission's Report, some features of the Report are worth discussing here. The Report in its Preface says, "We have found that extending the coverage of crucial health services, including a relatively small number of specific interventions, to the world's poor could save millions of lives each year, reduce poverty, spur economic development, and promote global security." Who has found this? Where is the data that supports such a claim? The data actually indicates that, to the contrary, technocentric top down interventions waste scarce resources. But clearly, the report starts from the premise that Health can be broken down to a few "magic bullets" appropriately delivered at a target. It is a premise that is the exact opposite of the essential tenets of public health.

The Report is also designed to set the ground rules for developing countries wanting to access funds from donors (read rich developed countries). In an unabashed defence of donor driven policies the Report says: "Where countries are not willing to make a serious effort, though, or where funding is misused, prudence and credibility require that large-scale funding should not be provided. Even here, though, the record shows that donor assistance can do much to help, by building local capacity and through the involvement of civil society and NGOs". The key message is clear: listen to donors, or else they will bypass sovereign governments and target NGOs and private institutions to drive their agenda through.

Possibly the clinching message in the Report is: "the Commission recommends that each developing country establish a temporary National Commission on Macroeconomics and Health (NCMH),…. The National Commissions would work together with the WHO and World Bank to prepare an epidemiological baseline, quantified operational targets, and a medium-term financing plan". Ask the Bank what is good for you even though you know they have made a mess on earlier ocassions!

The Report's signature tune is best summed up by its comments on the pharmaceutical industry: "The corporate principles that have spurred recent and highly laudable programmes of drug donations and price discounts need to be generalized ….Industry is ready, in our estimation, for such a commitment, enabling access of the poor to essential medicines, both through differential pricing and licensing their products to generics producers. ..… At the same time, it is vital to ensure that increased access for the poor does not undermine the stimulus to future innovation that derives from the system of intellectual property rights". While global opinion mounts against the pharmaceutical industry, particularly their inhuman role in denying treatment to millions infected with HIV/AIDS, the WHO is concerned about possible harm to the Intellectual Property System. Clearly, the Washington consensus now extends to Geneva!

CONTINUED RELEVANCE OF ALMA ATA DECLARATION

Almost twenty five years after the Alma Ata Declaration was issued, its relevance assumes even greater importance. There is, today, extensive evidence that public health has been an obvious casualty of the pursuance of neo-liberal economic policies across the world. There is a clear contradiction between the principal tenets of public health and neo-liberal economic theory that permeates policy making today. The former posits that public health is "public good", i.e. its benefits cannot be individually appropriated or computed, but have to be seen in the context of benefits that accrue to the public. Thus public health outcomes are shared, and their accumulation lead to better living conditions. Such goods never mechanically translate into visible economic determinants, viz. income levels or rates of economic growth. Kerala, for example, has low per capita income but its public health parameters rival those in many developed countries. The Infant Mortality Rate in Kerala is less than a third of any other large state in the country. But neo-liberal economic policies are loath to even acknowledge such benefits. The current economic policies would rather view health as a private good that is accessed by the medium of the market.