This somber message emerged from a Health Strategy Consultative Meeting held in Penang, Malaysia in late 1994. The meeting was organized by the International Peoples’ Health Council, the People’s Health Network and the Third World Network. It was attended by 20 health professionals and leaders of community-based health groups and non-governmental organizations from South Africa, Mexico, Palestine, Nicaragua, India, the Philippines, Malaysia, the United Kingdom, Australia and the United States.
David Werner, author of Where There Is No Doctor, the best-selling primer on community-based health practice, is perhaps the world’s leading critic of the quiet shift in global and national health strategies.
A consultant for the World Health Organization (WHO), Werner works with the U.S.-based Work Group for People’s Health and Rights. He recalled how governments almost unanimously endorsed primary health care at the landmark 1978 WHO-United Nations Children’s Fund (UNICEF) global health conference. The conference endorsed the Alma Ata Declaration, which was named for the Kazakhstan town where the conference was held.
To strive toward “Health for All by the year 2000,” the Declaration resolved that all people are entitled to basic health rights and that society (and thus government) has a responsibility to ensure that people’s health needs are met regardless of gender, race, class or degree of disability. The declaration’s centerpiece was primary health care, a comprehensive strategy that includes an equitable, consumer-centered approach to health services and addresses underlying social factors that influence health.
Alma Ata called for health ministries and health workers to be accountable to the common people and social guarantees to ensure that the basic needs (including food) of all people are met. “Unhappily, these high expectations have not been met,” said Werner. “Today it is painfully evident that the goal of Health For All is growing more distant not just for the poor but for humanity.” In the 1980s, a disturbing trend emerged: while child mortality rates dropped, malnutrition and morbidity rates rose. In the late l980s and early l990s, the decline in child mortality rates slowed or halted, and in many countries, especially in Africa, child mortality is now rising.
In many countries, improvements in health have slowed or stopped in recent years. In some countries, rates of malnutrition, tuberculosis, cholera, sexually transmitted diseases, plague and other diseases have increased dramatically.
According to Werner, three factors have undermined primary health care. First, instead of adopting a comprehensive health and social program as envisaged, UNICEF compromised, opting for selective primary health care aimed at reducing child mortality through the use of selected medical technologies, particularly oral rehydration therapy (ORT) and immunization.
This compromise was not entirely of UNICEF’s choosing. Due to inadequate response from donor countries, which was compounded by economic recessions, it was impossible to embark on a comprehensive primary health care program. Instead, UNICEF adopted a limited approach focused on providing ready-made packages rather than on teaching communities basic health skills. These programs were of limited success and their modest gains are proving difficult to sustain. Werner said that ORT and immunizations now are on the decline in many countries.
The ORT program promoted sales of ready-made oral rehydration salt packages rather than teaching the use of inexpensive family-prepared “home fluids.” The poor find it increasingly hard to afford these salt packets: some families spend a fourth of their daily income for a single packet.
Another setback to primary health care was the introduction in the 1980s of structural adjustment programs imposed on indebted Third World countries by the World Bank and International Monetary Fund as a condition for debt rescheduling. Structural adjustment policies include cutbacks in public spending, reducing government deficits by imposing or raising fees for health and other social services, freezing wages and freeing prices, privatization and reducing government jobs.
“These policies hit the poor hardest,” says Werner. “Budgets for so-called non-productive government activities such as health, education and food subsidies were ruthlessly slashed. Public hospitals and health centers were sold to the private sector, thus pricing their services out of the reach of the poor. Falling real wages, food scarcity and growing unemployment pushed low-income families into worsening poverty.”
A third factor which Werner says has “put the nail in the coffin of the Alma Ata Declaration” is the increasing role of the World Bank in global health policy planning, based on the same philosophy as structural adjustment.
The Bank’s health approach is spelled out in its World Development Report 1993. It calls for governments to: foster an enabling environment for households to improve health; improve government spending in health; and promote diversity and competition in health services.
Werner has his own interpretation of this Bank rhetoric:
• “Foster an enabling environment” means requiring disadvantaged families to pay for their own health, in other words fee-for-service and cost-recovery through user-financing that shifts the burden of health costs to the shoulders of the poor.
• “Improve government spending on health” means trimming government spending by reducing services from comprehensive coverage to a narrowly selective, cost-effective approach, or a new brand of selective primary health care.
• “Promote diversity and competition” means turning over to private doctors and businesses most of those government services that used to provide free or subsidized care to the poor. This implies privatization of most medical and health services, thus pricing many medical interventions beyond the reach of those in greatest need.
“Many health groups fear the Bank will impose its recommendations on those poor countries that can least afford them,” according to Werner. “What makes the new health strategy especially dangerous is that the Bank, with its enormous money-lending capacity, can force poor countries to accept its blueprint by tying it to loans.”
Werner’s concerns were broadly shared by other participants. According to a leading health expert and organizer in India, Dr. Mira Shiva of the People’s Health Network, structural adjustment in India has led to increasing food prices and unemployment, causing a deterioration in health. There is also a significant cut in the government’s health budget and the World Bank has stepped into the financial vacuum with new loans in the health sector. “The problem is that with one hand the Bank’s policies are taking away the health services the government used to provide to the needy and with another hand the Bank is giving money for health on a loan basis to be repaid,” said Dr. Mira.
Professor David Sanders, director of the Public Health Programme in the University of Western Cape, South Africa, has conducted extensive studies over the past four years on the impact of structural adjustment on health. He told the meeting that structural adjustment programs affect health indirectly, through general economic decline and changes in other sectors such as education, and directly, through policy changes in the health sector. In Zimbabwe, for example, where Sanders reported, health status has been affected by factors outside the health sector such as a decline in real wages, the removal of food subsidies and school fees or levies.
Within the health sector itself, there have been budget cuts that have reduced mobile health clinics and services (resulting in a fall in child immunization), lack of maintenance of medical equipment and hospital buildings, reduced supply of medicines and increased user charges.
— Martin Khor/Third World
The report found that when job creation aspects of pollution control policies are factored in, environmental protection has slightly increased net employment in the U.S. economy. And actual layoffs from regulation have been “startingly small,” according to the report.
The report found that:
• The great majority of economy-wide studies show a small positive effect of environmental regulation on overall employment. Environmental protection raises employment levels because it makes intensive use of labor or domestically produced materials or because it provides some recession-proof stimulus to aggregate demand.
• Few manufacturing plants have been shut down because of environmental protection. Government data from the late 1980s reveal that, on average, four plants per year shut down as a result of environmental or safety regulation. These accounted for less than one-tenth of 1 percent of all large-scale layoffs.
• Environmental regulation is not responsible for the long-term decline of manufacturing employment in the United States. The “pollution haven” effect — in which industrial firms relocate to poor countries to take advantage of lax environmental regulation — rarely occurs. Firms are relocating, but the overwhelming reason is lower labor costs.
• In the mining and logging industries, where trade-offs between jobs and the environment are most evident, local job loss from regulation can be significant. Even here, however, new jobs are generated elsewhere in the economy to provide substitute products for the timber or minerals preserved. They are also created in fishing and tourism and in industries seeking high “quality of life” for their employees.
The report noted that the jobs versus the environment debate has been fueled by “deindustrialization” — the loss of over 3 million manufacturing jobs in the United States during the 1980s, due in part to increased import competition, shifts in demand and technological change.
Environmental regulation has often been blamed for contributing to a shift in the U.S. economy from manufacturing jobs to service employment. Industry critics have argued that environmental protection measures have led to plant shut-downs, encouraged the flight of U.S. manufacturing capital overseas and reduced domestic investment by hampering productivity growth.
But the report found the employment effects of shutdowns, capital flight, and productivity losses from environmental protection have been small or non-existent.
At the same time, the report found that money spent to protect the environment has in fact created jobs. In 1993, some 4 million people were employed directly or indirectly in the “environmental protection industry.” Because much of the environmental spending is either labor intensive (recycling and sewage construction) or uses domestically produced capital goods (air-pollution control equipment), most studies indicate that environmental spending boosts aggregate employment.
Eban Goodstein, the author of the report, points out that the personal and social costs of job loss, whether they arise from environmental protection measures or general causes, cannot be minimized. But, he says, the trade-offs are local and, in contrast to the amount of notoriety they have received, extraordinarily small. More job loss appears likely as a result of corporate downsizing, import competition, and defense cutbacks, Goodstein says.
Goodstein argues that markets for clean manufacturing and energy technologies can provide the kind of high-wage boost to the U.S. economy that autos and defense provided in the 1950s and 1960s.
“As we move into the twenty-first century, demand for clean technologies will be the driving force behind industrial job creation,” Goodstein says. “Insuring that U.S. firms develop and maintain the lead in these fields will allow the country to capitalize on high-wage employment opportunities in environmental protection.”
— Russell Mokhiber