WORLD BANK : PUTTING A PRICE ON HEALTH ! Campaign for a universal access to Health Campaign n° 65, October 2003 – January 2004 With the support of : AC ! (Agir ensemble contre le chômage) ; AFASPA (Association française d'amitié et de solidarité avec les peuples d'Afrique) ; AFVP (Association française des volontaires du progrès) ; Agir pour l'environnement ; AMI (Aide médicale internationale) ; Arche de Lanza del Vasto ; ASTS (Association science technologie société) ; ATTAC (Association pour la taxation des transactions financières pour l'aide aux citoyens) ; CADTM France (Comité pour l'annulation de la dette du tiers-monde) ; CEDIDELP (Centre de documentation internationale pour le développement les libertés et la paix) ; CIDR (Centre international du développement et de recherche) ; Citoyens, Défense et Paix ; CNAFAL (Conseil national des associations familiales laïques) ; EMDH (Enfants du monde - droits de l'homme) ; Fédération CFDT banques et sociétés financières ; Fédération des syndicats SUD rail ; Fédération nationale accueil paysan ; Franciscain International - France ; GISTI (Groupe d'information et de soutien des immigrés) ; Initiative de développement stratégique ; Ligue des droits de l'homme ; Mouvement de la paix ; Partage ; Peuples solidaires ; RENAPAS (Rencontre nationale avec les peuples d'Afrique du Sud) ; RITIMO (Réseau d'information tiers-monde) ; Solidarité laïque ; SOS enfants sans frontières ; Terre des Hommes France ; Union syndicale G10 solidaires. Campaign Objectives This campaign aims to promote a universal access to healthcare and to reassert the role of the Government as guarantor of the universal right to health. In order to do so we are asking the World Bank to : · Cease promoting the privatization of health services and to redirect its financing towards public and supportive health system ; · Stop supporting the utilization of user fees, which limit the access to health for the poorest populations ; · Deliver its aid through grants instead of loans, so that financing access to health no longer adds to States' indebtness. Directions for use : 1. Sign the postcards and get them signed by relatives then send them to the President of the World Bank as well as the French representatives at the World Bank (the Minister of Finance and the Executive Director). 2. Return the detachable coupon to Agir ici so that we can have the participation rate at disposal during meetings with decision-makers and so that we can inform you about the results of the campaign. 3. Order campaign documents and distribute them around you : friends, fellow workers, associations, media of your region, etc. Why this campaign? On the 12th of September 1978, 134 member states of the World Health Organization (WHO) made a declaration of intent promoting a universal access to health by the year 2000. Access to health services is indeed a fundamental human right that should be fully and freely exercised by all in the North as well as in the South. Unfortunately, Twenty-five years after the declaration, it is obvious that 'universal access to health' is still far from being a reality. Governments have recently committed themselves to the achievement of the “Millennium Development Goals” by 2015. We, however, remain very skeptical as to the realization of such goals. The most vulnerable people continue to suffer from catastrophic sanitary conditions. 30,000 children die every day, access to basic healthcare being denied to them. HIV/AIDS epidemic kills thousands of people on a daily basis just because they cannot have an access to treatment. 600,000 women die each year from complications arising during childbirth, pregnancy and abortion. International financial institutions such as the World Bank and the International Monetary Fund (IMF) are largely responsible for such a situation. Structural adjustment programs (PAS), which were imposed on some countries by the World Bank and the IMF, are one of the main reasons explaining the degradation of healthcare systems in these countries over the past twenty years. The World Bank's healthcare model, partly based on privatization and user charges, can only widen the gap between the rich and the poor, or the sick and the healthy. Given this unacceptable situation, we must urgently organize collective action so as to claim the right to a truly universally accessible healthcare. Let us demand to the World Bank to stop promoting a model that reduces health to a mere commodity. Health is a public good that must be guaranteed to all by every Government. Structural adjustment against health public spending Structural adjustment programs, still in effect despite the adoption of new poverty reduction strategies, were introduced by international financial institutions following the debt crisis in the early 80s. Their basic objective is to increase government income in order to enable the debtors to repay their debts. In this context, investments in basic services are not considered as being a priority. Governments are forced to reduce their expenses and consequently, their budget for social services. The poorest countries' annual health expenses rarely exceeds 15 dollars per inhabitant, which amounts to a mere 1 per cent of the budget spent on each citizen's healthcare in developed countries. Such a level of expense (a far cry from the 30 to 40 dollars expenditure recommended by the World Health Organization) is insufficient, to say the least, for solving health problems in these countries. It is necessary to reconsider the use of adjustment programs and the cutbacks in public spending that comes with it. This is an absolute necessity if we want the State to take on its role as guarantor of a universal access to healthcare. Unfortunately, the World Bank has gone in the opposite direction by pushing for private provision of health services and promoting user fees. User charges : unaffordable for vulnerable people Urged by the World Bank, Southern countries have developed from the end 80s, healthcare systems based on user fees. This policy has dramatic consequences for the poor. Following its application in Zimbabwe, maternity costs have increased by 257 per cent, and childbirth through medical care nowadays costs twice the average monthly wages. The destitute cannot face such expenses. A system of exemption was put in place to spare the poorest but its inefficacy is manifest, as the World Bank itself admits. Nevertheless, this institution continues to support programs introducing unaffordable user charges for the majority of southern countries. Private provision of essential services : the risks for the poor The liberalization trend that public services are currently facing will only grow stronger under the combined effect of policies adopted by the World Trade Organization (WTO) on the one hand, and by international financial institutions on the other. The World Bank's private sector development strategy, adopted in 2002, confirms its intention to let the private sector play a greater part in the field of public services. The United Nations Development Program (UNPD) is very much concerned by this growing trend and has declared in its 2003 report that “the supposed benefits of privatizing social services are elusive with inconclusive evidence on efficiency and quality standards in the private relative to the public sector” whereas “unsuccessful cases abound”. As regards healthcare, if private not-for profit service providers (like NGOs) play an important role given the emergency of the situation in poorest countries, a purely commercial conceptualization of access to healthcare and to medical treatments would make, on the contrary, social inequality only more acute. In the absence of government regulation of health services, using private providers is likely to develop a double standard : the rich, paying for having access to “quality” health services, will leave the poorest in the care of a deficient public service lacking the means to meet their needs. Rather than opening the door to privatization, the World Bank should encourage improvement and reforms of public health systems, which have been impaired by twenty years of “structural adjustment”. In doing so, the World Bank would enable Governments to live up to their role. The problem of women comes first The right to sexual and reproductive health is a fundamental issue that concerns all women. Nevertheless, women are exposed to a high mortality rate due to inappropriate handling of complications arising during childbirth, the lack of treatments for girls, high-risk abortion, and HIV infection. The privatization of healthcare and the obligation to pay treatments, as encouraged by the World Bank, could only worsen the situation as women become poorer (according to the United Nations Development Program, women constitute 70 per cent of the poor population). As an example, in Nairobi, Kenya, the number of visits to a hospital specialized in treating Sexually Transmitted Diseases dropped by 65 per cent further to the introduction of user fees in Kenya. The poor: sick from debts In most developing countries, the debt crisis has led to dramatic social impacts : the 41 most indebted poor countries spend three times as much paying off the debt than for providing healthcare to their fellow countrymen. Projects of the World Bank in the Health sector play a direct role in the increase of the Government debt : by allocating its financial aid through loans rather than grants, the World Bank actually increases the debt of the recipient country and finally restricts the use of funds actually dedicated to public health services. This is all the more unacceptable given the fact that so far these projects have not helped improve significantly healthcare quality and access for the poor. Since universal access to health is a priority and must not lead to Government indebtness, the World Bank must deliver its aid through grants instead of loans. The World Bank has adopted such a stance toward some projects against the proliferation of AIDS; it must now do likewise for all of its projects in the health sector. AIDS: the choice between life and debt One out of five people in Zambia are HIV positive and AIDS is spreading at the rate of 500 new cases per day. Crushed by the burden of its national debt, Zambia does not have the means to face this catastrophic situation. Knowing that 40 per cent of the budget is swallowed up by repaying the debt, the 6.7 per cent that is spent on social services appears insignificant. A 100 per cent cancellation of public debts and a significant increase in the national health budget is critical. In the absence of such measures, Zambia will be unable to contain the spread of AIDS, thereby condemning a large part of its population to a certain death. Privatization will not spare the North The privatization of health services is not specific to the 'South'. Since the creation of the World Trade Organization in 1994 and the conclusion of the General Agreement on Trade in Services (GATS), industrialized countries are also directly affected by the process of privatization of the public services. In fact, northern Governments seem to have committed themselves to this process. By deeming public health to be a cost rather than a positive investment benefiting the population, political leaders are working on a gradual shift in public opinion towards an acceptance of an increasingly privatized healthcare system. Under the banner of reforms, the very existence of the French health insurance system is currently under threat. The increasing deficit calls for resolution. however, its reform must be carried out bearing in mind what equity and social justice entail. Citizens take action at local and global levels In El Salvador Since 1999, the medical profession has been opposing the Government's attempt, pressured by the World Bank, to privatize health services. Hundreds of citizens have on several occasions joined the strikes organized by the medical body. This mass protest has gained the support of the Parliament which adopted in November 2002 a motion proclaiming a “state-guaranteed health service and social security system”. However, the issue of privatization is likely to remain on the agenda since the World Bank is still requiring a stronger involvement of the private sector in social services provision. Today, Collective action continues to take place in El Salvador, the people being determined to defend their right for an equitable access to health services. This mobilization has the support of many international organizations, such as the Social Justice Committee in Canada. International campaigns Numerous actions are being taken in favor of the universal right to health. You can give your support to them : - The 'million signature campaign' organized by the International People Health's Council (www.iphcglobal.org). - The 'People's Charter for Health' initiated by People's Health Movement (www.phmovement.org). - The 'Women's Access to Health Campaign' initiated by Women's Global Network for Reproductive Rights (www.wgnrr.org) - The 'debt and health campaign' led by the Centre National de coopération au développement (www.cncd.be) What are the alternatives? A generalized system of user fees could hardly give a suitable answer to help poor people to get an access to health. Alternative solutions that are more supportive and democratic must be developed in order to guarantee a universal access to healthcare. Community-based health insurance systems Confronted with a deficient public service, some of the poorest communities have established their own welfare system. In Mali, for instance, small-scale cotton producers have created a health insurance system that covers all villagers. The system is funded by each producer's contributions from their own harvest. A State-guaranteed social security Solidarity must also be present at the national level. As the International Labor Organization reminds us, all Governments must provide its citizens with an effective and egalitarian social security. It is important that this obligation would not be denied by the World Bank so that budgetary resources could be allocated freely. The creation of a global social security system? On a global level, healthcare in the “South” must receive greater financial aids from wealthier countries. Being a global public good, health must be founded on solidarity between industrial and poor countries. Could the idea of a 'global social security system,' increasingly evoked by institutions such as the World Health Organization and the United Nations Development Program, meet such needs? For more information… Bibliography Macroéconomie et santé : investir dans la santé pour le développement économique, OMS, Commission Macroéconomie et santé, décembre 2001 ; Mondialisation et santé, Médecins du Monde, janvier 2003, 20 p., www.medecinsdumonde.org ; « Le financement privé dans les secteurs de la santé, de l'éducation et de l'eau », Rapport mondial sur le développement humain, chap. 5, PNUD, 2003 ; « SAPs – Globalisation and the Impact on Health, a Third World View », Evelyne Hong, août 2000, http://phmovement.org/pubs/issuepapers/hong08.html ; User Fees : the Right to Education and Health Denied, The Coalition for Health and Education Rights, mai 2002, 12 p., www.campaignforeducation.org/_html/2002-docs/ 05-cher-fees/cher-userfees.pdf ; Globalisation, Privatisation and Healthcare, David Hall, PSIRU, 2002, 19 p., http://attac.org/fra/toil/doc/psiru04.htm ; Stratégie de développement du secteur privé, Banque mondiale, avril 2002, 119 p., http://rru.worldbank.org/documents/PSDStrategy-April%209.pdf . Web sites : Act Up-Paris : www.actupp.org Agir ici : www.agirici.org Attac : www.france.attac.org AITEC (Association internationale de techniciens, experts et chercheurs) : www.globenet.org/aitec/ CNCD (Centre national de coopération au développement) : www.cncd.be CNES (Citizens'Network on Essential Services) : www.servicesforall.org CRID (Centre de recherche et d'information pour le développement) : www.crid.asso.fr France Libertés : www.france-libertes.fr/intro.htm GRDR (Groupe de recherche et de réalisation en développement rural) : www.grdr.org Medact : www.medact.org Médecins du Monde : www.medecinsdumonde.org MFPF (Mouvement français pour le planning familial) : www.planning-familial.org PSIRU (Public Services International Research Unit) : www.psiru.org The Social Justice Committee : www.s-j-c.net Wemos : www.wemos.nl