Who killed Primary Healthcare?

How the ideal of ‘health for all’ was turned into the reality of
worsening health for the world’s poor.

An instructor of community-health workers in Kenya once told me about a sobering experience she had when she was visiting a rural health post. In the heat of midday an exhausted young mother arrived on foot from an isolated hut several kilometres away in the savannah. In a colourful shawl across her back she carried her baby, Kofi, who – she explained – had severe ‘running stomach’ and was very ill. She begged the health worker for the life-saving medicine in the silver envelope that she had heard about on the radio. She was referring to Oral Rehydration Salts, of which 400 million packets are produced each year as part of the international campaign to reduce deaths from diarrhoea, still the biggest killer of children in many poor countries.

Lovingly the mother lifted little Kofi from the shawl then gave a sudden cry of despair. Kofi was dead. His wrinkled little body made it clear that he had died of dehydration. The long trip in the hot sun had been too much for him.

‘I felt partly responsible,’ sighed the instructor. ‘If we had only taught mothers to make a home-made rehydration drink instead of teaching them that they needed a “magic packet with a silver lining”, her baby might still be alive today. But we listened to the experts in Geneva and Washington.’

As a stop-gap measure for undernourished children Oral Rehydration Therapy (ORT) should certainly be given high priority. But it must be introduced in ways that foster self-determination, not dependency. On my travels to the villages of Africa, Asia and South America I have heard many similar stories of acclaimed technological solutions that have not lived up to their promises.

Primary Healthcare (PHC) as originally outlined by the world’s nations at the 1978 Alma Ata Conference did indeed seek to establish the accountability of health workers and health ministries, with guarantees to meet the basic needs – including food needs – of everyone. This commitment was based on the success of community-based health programmes that had sprung up in the Philippines, Guatemala, India and elsewhere. The barefoot doctors of revolutionary China had demonstrated that with political will for equity a state could achieve good health at low cost.1

Unhappily, the high expectations of Alma Ata have not been met. Three major changes have sabotaged them.

Selective Primary Healthcare
No sooner had the dust settled after the Alma Ata Conference than top-ranking health experts in the North began to trim the wings of Primary Healthcare. With global recession and shrinking health budgets they felt that such a comprehensive approach would be too costly. If health statistics were to be improved, they argued, high-risk groups must be ‘targeted’ with a few cost-effective interventions. This politically sanitized version was dubbed Selective Primary Healthcare.

UNICEF, which had been a strong advocate of the comprehensive original, now took the line that Selective PHC was more ‘realistic’. Through its so-called Child Survival Revolution’ (which some critics called a counter-revolution) UNICEF narrowed the focus to growth monitoring, ORT, breastfeeding and immunization. In most countries it was narrowed even further to the ‘twin engines of child survival’, ORT and immunization.

The global Child Survival Campaign quickly won high-level support. For those in positions of privilege and power it was safe and politically useful. It promised to improve a widely accepted health indicator – child mortality – while skirting in all but rhetoric the social and economic inequities underlying poor health. Many health professionals and governments jumped on the bandwagon. Even the World Bank began to lend its support.

But technological solutions can only go so far. Over 133 million children still die each year, roughly the same number as 15 years ago, even if this represents a smaller percentage of an increased child population. Most of these deaths are still related to poverty and undernutrition.

Reducing child mortality through selected technological interventions does not necessarily improve children’s health or quality of life. During the 1980s a disturbing pattern emerged in some poor countries: while child-mortality rates dropped, undernutrition and morbidity rates increased. The pattern was ominous. Sure enough, during the late 1980s and early 1990s, in many countries the decline in child mortality slowed or halted. While in some countries – especially in sub-Saharan Africa – child deaths began to increase.2

Even the ‘twin engines’ of child survival proved difficult to sustain. Immunization rates began to decline, with a corresponding increase in polio cases. Egypt’s oral-rehydration program, which has been upheld as a success story, saw usage rates for oral rehydration salts in the 1990s plunge from more than 50 per cent down to 23 per cent.2 Salts packets were originally given to mothers free. Their provision was then commercialized. Now poor families are brainwashed into spending food money on these products rather than using potentially more effective, less expensive, home-made cereal drinks. A ‘simple solution’ for child survival became yet another way of exploiting the poor.

Hilary Clinton beams: but dissent was the most interesting thing about the Social Summit in Copenhagen.

Structural Adjustment Programmes
The next big assault on Primary Healthcare was the introduction during the 1980s of Structural Adjustment Programmes (SAPs). Engineered by the World Bank and IMF, these austerity policies invariably hit the poor hardest. Public hospitals and health centres were sold to the private sector, pricing their services out of the reach of the poor.

‘User-financing’ and ‘cost-recovery schemes’ are among the most pernicious of these policies. The poorest families tend to get sick most often and so pay the most. They are often willing to spend their last pennies to care for their sick children. But they can ill afford to do so. In the Makapawa community-based health programme in the Philippines, health workers found that the money poor families spent on medicines instead of food contributed to child undernutrition and high mortality. By making remedies for common problems at home they spent less on pills, more on food, and their children’s health improved.

Studies in some countries have shown that when cost-recovery was introduced the use of health centres by high-risk groups dropped. In Kenya the introduction of fees at a centre for sexually transmitted diseases caused a sharp decline in attendance and an increase in untreated infections.3 In China user fees for tuberculosis treatment led to millions more cases of infection.

‘Investing in Health’
The third assault on Primary Healthcare came with the World Bank’s 1993 World Development Report, ‘Investing in Health’. A better title might have been ‘Turning Health into an Investment’. For when stripped of its humanitarian rhetoric its chilling thesis is that the purpose of keeping people healthy is to promote economic growth.4 If such economic growth were intended to serve the well-being of all then the Bank’s intrusion into healthcare might be more palatable. But the ‘economic growth’ which the Bank promotes has invariably benefited large multinational corporations, often at devastating human and environmental cost.

On first reading, the Bank’s strategy looks comprehensive, even modestly progressive. It acknowledges the economic roots of ill health, and that improvements are likely to result primarily from advances in non-health sectors. It calls for increased family income, better education (especially for girls), greater access to healthcare, and a focus on basic health services rather than specialist care. It quite rightly criticizes the persistent inequity and inefficiency of current Third World health systems. Ironically, in view of its track record of slashing health budgets, the Bank even calls for increased health spending.... So far so good.

But, on reading further, we discover that the key recommendations spring from the same paradigm that has worsened poverty and health levels. To save ‘millions of lives and billions of dollars’ governments must adopt ‘a three-pronged policy approach of health reform’:

  • ‘Foster an enabling environment for households to improve health’ – which really means requiring disadvantaged families to cover the costs of their own healthcare.

  • ‘Improve government spending in health’ – meaning trimming government spending from comprehensive coverage to a narrow selection of cost-effective measures.

  • ‘Promote diversity and competition in health services’ – which means turning over to private, profit-making doctors and businesses most of those government services that used to provide free or subsidized care for the poor.

One reviewer (David Legge) observes that the World Bank Report ‘is about healthier poverty’.5 It ignores the fact that in many countries with SAPs average per-capita income has plummeted. Even in countries whose economies have partially recovered, most gains have been pocketed by the wealthy.

The Bank’s new policy for the Third World sounds dangerously like the healthcare model of the US. It argues that private healthcare for individuals gives more choice and satisfaction and is more efficient. But there is little evidence to support this claim. The US health system, dominated by a profit-hungry private sector, is by far the most expensive in the world. Yet US health statistics are among the worst in the Northern industrialized nations. The city of Washington DC has higher child- and maternal-mortality rates than Jamaica.

It is an ominous sign when a giant financial institution with such strong ties to big government and big business bullies its way into the health field. According to the British medical journal, The Lancet, the World Bank is now moving into first place as the global agency most influencing health policy, even ahead of the World Health Organization.6

Despite all its humane-sounding rhetoric, the central function of the World Bank remains the same: to draw the governments of weaker states into a global economy dominated by large, multinational corporations. Its loan programmes, development priorities and adjustment policies have deepened inequalities and added to the poverty, ill health and deteriorating living conditions of at least one billion human beings.

Mexican model
I have seen for myself how community action can turn the tables. Based in the mountains of western Mexico is Project Piaxtla, a villager-run health programme. Analysing the factors behind the high death rate of children from diarrhoea and undernutrition, the health team there saw that a key cause was share-cropping – poor, landless families must give up half their harvest to the rich landowner.

They realized that conventional health measures were not enough to improve the survival and quality of life of children. By organizing peasant invasions of illegal holdings they succeeded in redistributing over half of the best, riverside land. With irrigation they doubled the yield, giving poor farming families more to eat. Their children gained weight and succumbed less to common health problems. The death rate of under-fives dropped from 34 per cent to around 6 per cent.

In explaining the dramatic improvement people gave some credit to better healthcare but said the big difference was their joint struggle to win their constitutional land rights. Such an interpretation of health is consistent with the Alma Ata Declaration’s insistence that health depends on equity. Most children can survive without medicine, none without food.

Unfortunately, in the 1990s the peasant farmers of Mexico are seeing the gains they made reversed. Mexico has an enormous foreign debt and in exchange for new loans has been subjected to stringent adjustment policies. Land-ownership is concentrating again into fewer hands – including those of US agribusiness transnationals. More than a million small farmers have lost their holdings and migrated to city slums, where unemployment soars.

The village health team in Mexico, along with thousands of concerned groups around the world, are coming to realize that new strategies – comprising local action with global solidarity – are needed to counter the transnational power structure. Although the obstacles are colossal, there are encouraging signs that such a groundswell is under way. The ‘50 Years is Enough’ international coalition, which opposes the exploits of the World Bank and the IMF, is a good example. Many networks focusing on health are striving to increase public awareness and to organize pressure from below on the world’s policy-making bodies. Two such grassroots coalitions based in the South are the Third World Network in Malaysia, and the International People’s Health Council in Nicaragua.

At the recent Social Summit in Copenhagen nearly 1,000 non-government organizations and people’s movements joined in protesting the official Declaration, calling for fairer distribution of resources and restructuring of the world order so that poor and disadvantaged people have a stronger say in decisions that determine their well-being.

In the final analysis, creating a healthier social order will depend on reaching across traditional barriers and replacing global pillage with a global village – where everyone’s basic needs are equitably and flexibly met.

This article appeared in The New Internationlist, 1995.