Global ills won't find a cure in the market

THERE is more to health policy than just policy for the health sector. But the World Development Report 1993 clearly shows the mandarins -- read health experts -- of the World Bank have trivialised the issue because holism is a philosophy they still have to learn. Surely, for a hungry person, pills and doctors can wait till a full meal is found. But there is hardly a word in the report about food security in the context of the world"s current health status. Similarly, the extreme work burden on poor rural women that emerges from environmental degradation and affects their health, does not receive any mention.

Trust the World Bank to remain steadfast to its ideology of privatisation and support for the market. Just as an antique Persian dagger, albeit a work of art, is a lethal weapon, so also is the bank"s report on "Investing in Health" equally lethal. If structural adjustment is likely to exacerbate poverty, a good safety net would be necessary to support the poor. But who will pay for this safety net? The bank typically glosses over the responsibility of the global rich, though its integrationist policies together with those of its counterpart, the IMF, are pushing for a globalised world. And all the recommendations are aimed at its weaker partners -- the governments in the developing world.

World health spending is rising. In 1990, public and private expenditure on health services worldwide was about US $1,700 billion, or 8 per cent of the total world product. High-income countries spent almost 90 per cent of this amount, at an average of $1,500 per person, while developing countries spent about $170 billion, or 4 per cent of their GNP, for an average of $41 per person. The US alone consumes more than 41 per cent of the global total, more than 12 per cent of its GNP. Clearly, what matters is that people of the developing world are poor and their right to life is not as important as that of a US citizen.

The report centres on a beautiful device: the disability adjusted life year or DALY -- a measure that combines healthy life years lost because of premature mortality with those lost as a result of disability. Analysis of the total DALY loss -- the global burden of disease -- shows it is the highest in the poor countries, though disability remains a burden in all regions. If death rates among children in poor countries were reduced to those of the rich countries, 11 million fewer children would die each year.

The report recognises almost half of these deaths are preventable and occur due to diarrheal and respiratory illnesses, exacerbated by malnutrition -- all caused largely by poverty. In addition, for example, 7 million adults die every year of conditions that could be inexpensively prevented or cured; tuberculosis alone causes 2 million of these deaths. About 400,000 women die from the direct complications of pregnancy and childbirth; maternal mortality ratios on the average are 30 times as high in developing countries as in high-income countries.

The World Bank lays down that provision of cost-effective health services to the poor is an effective and socially acceptable approach to poverty reduction. But where is the investment going to come from? The bank states that the poor lack access to basic health services and receive low-quality care. Much of the money spent on health is wasted as brand name pharmaceuticals are purchased instead of generic drugs. Health workers are badly deployed and supervised and hospital beds are under-utilised.

Southern governments will have to solve these problems by spending "on an average 50 per cent less" than they do now on expensive interventions. Instead, they will have to double or triple spending on basic public health programmes such as immunisation and AIDS prevention and on essential clinical services. And -- read on carefully -- since competition improves quality and drives down costs, the bank prescribes that governments should foster competition and diversity in the supply of health services and inputs, particularly drugs, supplies and equipment. In doing so, it dismisses in a few lines China"s community-based health services, which made it one of the few low-income-high-health countries in the world.

Indeed, the bank"s logic is infallible. Spending on health is a productive investment because it raises incomes, especially among the poor, and it can reduce the extent of human suffering. The bank will give money to the developing world as aid, presumably only when its conditions are met.

Bangladesh, which has tried to develop an effective, anti-multinational drug policy, has been under constant attack ever since the policy was formulated in 1982. The bank"s report, developing the argument for private, market-regulated medical enterprise, cites a Bangladeshi example to make the point that a combination of protection and poor regulation can be particularly damaging. A truism -- but it does not ask MNCs to sell in the open market the same drug, but with different indications and contradictions, in the rich world as compared to the poor one. But the bank insists on telling us that improved selection and purchasing practices, rather than protection of drug manufacturing, is the best way of countering the market power of MNCs. Of course, cartels and monopolies are not talked about.

The bank is an economic institution. But when will it occur to the bank that health is linked to the nature and quantum of economic growth and the types of health problems mentioned in its report are precisely the kind that arises from top-down approaches that have been followed globally, between the developed and the developing world, and within the latter, between the rich and poor? It"s understandable that the report totally misses out on health-environment linkages and how degradation of the local environment creates first poverty and then disease. With the introduction of cash-oriented agriculture and the usurpation of the commons, many peasant families become ecological refugees and swell the ranks of the unemployed and increase the incidence of killer diseases.

What is not understandable is why the report does not discuss safety nets for the adjustment programmes that are taking place in most of the developing world, which, by its own admission, has had an adverse impact on their health services. If the package laid down by the report was adopted in all developing countries, $20 billion would be required annually in aid, compared with the present aid level of $5 billion. This would constitute an increase from $20 billion a year on essential clinical services to $40 billion. But from where would this money come?

We have an answer: Because a Northern bank must start by telling off the North, let World Bank president Lewis Preston examine a tax on global toxic waste production, which stresses the world"s carrying capacity to support a worldwide essential health service. It makes sense to tax something bad to support something good and such a tax would bring benefits to the North as well as the South.

And, Preston should tell the US Congress or the British Parliament to go jump in the nearest polluted lake, if either balks at paying the bill.