Health for All

Health Care as a Commodity

Jayanta Bhattacharya

Health for All by the Year 2000" was an ambitious and worthy goal. But even those who formulated it back in 1978 did not fully grasp its meaning. No wonder that 40 years later India is yet to realise all the dreams of the first International Conference on Primary Health Care. 2017 marks the 39th anniversary of the first International Conference on Primary Health Care in Alma-Ata, Kazakhstan, an event of major historical significance. Convened by the World Health Organisation (WHO) and the United Nations Children’s  Fund (UNICEF), Alma-Ata drew from 134 countries, 67 international organisations and many nongovernmental organisations. China, unfortunately, was notably absent.

 After 40 years, it may be safely said that the concept has been repeatedly misinterpreted and distorted. It has fallen victim to oversimplification and voguishly facile interpretations, as well as to people’s mental and behavioral conditioning to an obsolete world model that continues to confuse the concepts of health and integral care with curative medical treatment focused almost entirely on disease.

Internationally, health has a history of “forgotten”-ness. When the Covenant of the League of Nations was drafted after the World War I the inclusion of health as an agenda was “forgotten”. Only at the last moment was world health brought in, producing the health Section of the League of Nations (K Evang, Political, national and trditional limitations to health control,” Health of Mankind, 1967, p. 202).  Although international participation in the League of Nations was limited, the Health Section of the League of Nations developed into one of the most successful and non-controversial parts of the organisation, making itself indispensable through its statutory functions. Evang wondered, “Who would have thought, therefore, that health was again “forgotten” when the Charter of the United Nations was drafted at the end of the Second World War?” However, the matter of world health had to be reintroduced more or less ad hoc at the United Nations 1945 conference in San Francisco in the spring. Shortly afterwards, in America “no one group has held so dominant a position... power as has the medical profession.” (Paul Starr, The Social transformation of American Medicine)

As the extent of profit accruing from health and health care as a global commodity was not much visible to the giant multinational companies (MNCs), world health was a “forgotten” issue then. For example, India was one of the fastest growing markets in 2006, with pharmaceutical sales increasing 17.5 percent to $7.3 billion. Any figure of 2017 must put it in a more lucrative shape.

Global pharmaceutical sales have reached $1.4 trillion in 2016 and more is expected in 2017 (IMS Health White Paper, 2016).  Companies currently spend one-third of all sales revenue on marketing their products – roughly twice what they spend on research and development. As a result of this pressure to maintain sales, there is now ‘ an inherent conflict of interest between the legitimate business goals of manufacturers and the social, medical and economic needs of providers and the public to select and use drugs in the most rational way’(WHO, Clinical pharmacological Evaluation of Drug Control, 1993). Companies currently spend one-third of all sales revenue on marketing their products – roughly twice what they spend on research and development.  Globally, 5.3 trillion dollars were devoted to health care in 2007 (World Health Report 2010). Though the exact figure is not readily available, it should have risen to a few more trillion in 2017.

Researchers and journalists have recently shown that the structural adjustment policies of the World Bank and IMF undermined government funding for health infrastructure in countries afflicted by Ebola. Being compelled to buy hi-tech medical equipment, these poor countries had little left for their primary health care structure to face Ebola. Another study from the Bretton Woods Project plainly states that decades of IMF lending to Ebola-affected countries in West Africa led countries to prioritise debt payment over investment in public services. Health services have been starved of investment, including vital public health infrastructure. Pressure on the IMF, including from the G20, to relax spending restrictions and forgive debts, is mounting.

It is intriguing to learn how forces of free market economy reconstituted the slogan of ‘Health for All’ and consequently, the “comprehensive primary health care” (CPHC) gave way to the “selective primary health care”. At the same time, virtual replacement of “health” by “health care” as well as primary health centres by the glittering five-star clinics and proprietary private hospital was not amiss. More significantly, the tenuous philosophical distinction between ‘‘clinical” or individual health and ‘‘public health” began to be erased and the two became virtually the same thing. Medical curricula too were overhauled, keeping in harmony with these transformations.

The Period of Nativity
Since the late 1940s; large number of Asian, African and Latin American countries won their freedom from the shackles of colonialism. After winning freedom, they were hard pressed with the need for the highest utilisation of human resources and the provision and access to health care for the people so long afflicted with war, poverty and hunger became a national agenda in its own right.            

Since the 1950s, some developing countries had invented health care programmes at the most peripheral level to meet the needs of the deprived populations. Each experience followed a particular approach. For example, China used mass education programmes and “barefoot doctors” to deliver primary health services. It was stressed that the model of the “barefoot doctors” in China had been able to address successfully the question of primary health care of the country. Besides, Tanzania, Cuba, Venezuela and Nairobi adopted comparable models to deliver primary health care provisions. A new perception of health care for the people ushered in as a consequence of all these endeavours. Since the beginning of the 1960s, David Werner – the author of the celebrated book Where There is No Doctor – took great initiative to mobilise rural population at the grassroots for promoting basic health care. In the period between the early 1960s and the late 1970s, the question of CPHC began to assume definite shape and orientation. Though the USSR was not a member nation of the WHO during the period 1949-57 it contributed to 6% of the annual budget of the WHO. After it became a member in1959, the figure was 13%.

However, during the late 1970s, China along with a number of African nations put a sustained pressure on the WHO to be more careful, attentive and active to extend primary health care both horizontally and vertically to the bottom most section of society across the globe. In an essay of 1971 – in no other journal than Paediatrics, volume 47, issue 6 – published by the American Academy of Paediatrics, it was observed that the influence of American and Western European ‘‘physician models,’’ system of medical education, and hospital-centred delivery systems upon developing countries has been nothing short of disastrous, and children have been the greatest sufferers.                               

The 1970s saw the cresting of the scientific and technological revolution that began with the end of World War II, a revolution that produced, among other major changes, what is today knowns as globalisation. But there was also a recognition of growing inequality among vast sectors of the world’s population. This recognition provided the impetus during the 28th and 29th World Health Assemblies in 1975-76 for the commitment to ‘‘Health for All in the year 2000.’’

Politically, the world was in a state of ideological and economic polarisation, as well as a historically new form of confrontation. But within the socialist bloc, there was also a major rivalry between the Soviet Union and China. This competition would prove decisive for the conference at Alma-Ata. At the same time, a number of developing countries had been trying, for a number of years and in various ways, to tackle health problems with limited financial, technological and human resources. Their experiences became the subject of scholarly studies in the 1960s mid 1970s, with China, India and some counties of Africa and Latin America emerging as the most often cited examples. Following the publication of some of these studies, WHO, under the leadership of Director- General Halfdan Mahler (1973-88), responded enthusiastically? Mahler saw clearly the worth of these experiences and began to promote them around the world as the responsibility of all countries, rich and poor.

Moreover, WHO was seeking ways to translate the emerging knowledge base into health care for people all over the world? The 1968-1975 period saw dramatic changes in the priorities that governed the Work programme of WHO. For more than a decade, the global malaria eradication campaign had been WHO’s leading programme. Initiated in the mid-1950s, it was a strictly vertical programme based on the insecticidal power of DDT.

The primary health care approach was introduced to the Executive Board of WHO in 1975. Parallel approaches were being taken by WHO and by the Christain Medical Commission (CMC) of the World Council of Churches. Long back in the late 1960s, CMC realised that hospitals became a factory for repair of things rather than a hospice for the care of souls. The growth of medical specialisation tended to break down the patient into pathological parts so that he is regarded or treated less and less as a whole patient. Three community-based experiences presented to the CMC between 1971 and 1973 proved to be critical in WHO’s conceptualisation of primary health care: (1) Central Java, Dr and Mrs (Dr) Gunawan Nugroho, (2) Jamkhed, India, Drs Raj and Mabelle Arole, and (3) Chimaltenango, Guatemala, Dr Carroll Behrhorst.

The first official meeting of WHO and the CMC took place in 1974. A joint working group was established, with Dame Nita Barrow and Dr Ken Newell designated as representatives from CMC and WHO respectively. Instead of the top-down perspective of health planning and systems analysis, priority was now being given to the bottom-up approaches of community involvement and development.

From the late 1960s, there was an increase in WHO projects related to the development of “basic health services” (from 85 in 1965 to 156 in 1971). These projects were institutional predecessors of the primary health care programmes that would later appear. Another early expression of change was the creation in 1972 of a WHO Division of Strengthening of Health Services. In addition, the assumption that the expansion of “Western” medical systems would meet the needs of the common people was again highly criticised. In 1978, the historic Alma-Ata conference took place from 6-12 September, 1978, which declared CPHC as the key issue in the promotion and protection of public health across the globe, especially among poor nations and economically vulnerable groups of any given society. Coincidentally, the eradication of smallpox was also complete in 1978.

This was the biggest landmark conference on health and primary health care. This conference was to an extent a reflection of the ideological and philosophical ideas of Dr Halfdan Mahler. Thirty years after the Alma-Ata conference, Dr Mahler said in an interview - “I expected it to become the most decisive conference WHO had organized after its foundation [1948]...The 1970s was a warm decade for social justice. That’s why after Alma-Ata in 1978, everything seemed possible. Then came an abrupt reversal, when the International Monetary Fund (IMF) promoted the Structural Adjustment Program with all kinds of privatization, and that drew scepticism towards the Alma-Ata consensus and weakened commitment to the primary health care strategy. WHO regions kept on fighting in countries, but there was no support from the World Bank and the IMF.” (Bull WHO 2008: 747-48)

For Mahler and others, “Health for All” was a social and political goal, but above all a battle cry to incite people to action. Its meaning, however, has been misunderstood, confused with a simple concept of programming that is technical rather than social and more bureaucratic than political. When Mahler proposed “Health for All” in 1975, he made it clear that he was referring to the need to provide a level of health that would enable all people without exception to live socially and economically productive lives (today we would say “a minimally dignified standard of living” in a context of “truly human development”). The reference to the year 2000 meant that, as of that date, all the world’s countries would have developed the appropriate political strategies and be carrying out concrete measures toward achieving this social goal, albeit within different time frames.

The process of conceptual development surrounding just what health is was also important. In 1946, the new WHO constitution incorporated a definition of health proposed by the Croatian public health pioneer Andrija Stampar. It said health was “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” This was a qualitative leap from earlier concepts, but it was difficult for many government experts of the time to fully grasp its meaning. The Declaration of Alma-Ata repeats this definition, adding that health is “a fundamental human right and that the attainment of the highest possible level of health is a most important worldwide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.”

Perhaps because of what might be called professional deformation, it was not really understood that health is a social phenomenon whose determinants cannot be neatly separated from other social and economic determinants. Nor can it be assigned solely to one bureaucratic-administrative sector of the state. Nor was it understood sufficiently – though it was spelled out clearly – that health is, above all, a complex social and political process that requires political decision-making not only at the sectorial level but also by the state, so that these decisions are binding upon all sectors without exception.

A quite explicit yet quite misunderstood fact is that health is the responsibility of everyone -individuals, social groups and civil society as a whole. In practice, people continued to be viewed as passive recipients of health services that emphasise curative medical treatment of specific illnesses.

The conceptualisation of “primary health care” was based on erroneous and biased perceptions of the experiences of Third World countries in providing health care with limited resources. In particular, the Chinese experience with “barefoot doctors” was interpreted simplistically and superficially.

There is a fundamental difference between integral health care for everyone and by everyone-care that is multi-sectorial and multidisciplinary, health-promoting and preventive, participatory and decentralised – and low-cost (and lower quality) curative treatment that is aimed at the poorest and most marginalised segments of the population and, what is worse, provided through programmes that are parallel to the rest of the health-care system without the direct, active and effective participation of the population.

The Countercurrents of History
There were robust attempts of subversion of the CPHC programme since the late 1970s. An economic theory which could negate the validity of health as a social right theoretically and marketing of health care as a commodity globally was much needed. The proponents of   neoliberal economics provided the vantage point to maneuver both jobs successfully. During the time, the US embraced the increasing power of medicine but did not similarly medical care as a social right.

Probably, Hayek’s The Constitution of Liberty (first published in 1900) is the first book to bring the question of health and health care within the ambit of neoliberal economics. He found that the case “for free health service is usually based on two fundamental misconceptions.”

In 1977 Alain Enthoven, then a consultant to the administration of President Carter, prepared a Consumer Choice Health Plan well suited to free market. It was later published in New England Journal of Medicine under the title ‘Consumer-Choice Health Plan – Inflation and Inequity in Health Care Today: Alternatives for Cost Control and an Analysis of Proposals for National Health Insurance.” In 1979, the proprietary-hospital business generated between $12 billion and $13 billion of gross income – an amount that was estimated to be growing about 15 to 20 percent per year (corrected for inflation). A major area of growth was overseas – in industrialised Western countries as well as underdeveloped countries – where much of the new proprietary-hospital development was then taking place. In the same year, $15 billion was spent on diagnostic laboratory services of all kind. As known from an article in Wall Street Journal of December 27, 1979, the net earnings of health care corporations with public stock shares rose by 30 to 35 percent in 1979 and were expected to increase another 20 to 25 per cent in 1980.

But some problems persisted. First, the classic laws of supply and demand do not operate because care consumers do not have the usual incentives to be prudent discriminating purchasers. Second, “the patient, when he thinks something is wrong with him, is not an economic man. He is fearful, ignorant, helpless, miserable creature. He does want health, almost at any price. He is not looking for what the economists call a ‘provider...The patient, in short, is looking for a trustee not a ‘provider’.

Concerned about the identification of the most cost-effective health strategies, the Rockefeller Foundation sponsored in 1979 a small conference entitled “Health and Population in Development” at its Bellagio Conference Centre in Italy. The goal of the meeting was to examine the status and interrelations of health and population programmes when the organisers felt “disturbing signs of declining interest in population issues.” The conference was based on a published paper (in NEJM) by Walsh and Wairen entitled “Selective Primary Health Care — An Interim Strategy for Disease Control in Developing Countries”. In the paper, and at the meeting, selective primary health care was introduced as the name of a new perspective. The term meant a package of low-cost technical interventions to tackle the main disease problems of poor countries. At first, the content of the package was not completely clear. For example, in the original paper, a number of different interventions were recommended, including the administration of antimalarial drugs for children (something that later disappeared from all proposals). However, in the following years, these interventions were reduced to 4 and were best known as GOBI, which stood for growth monitoring, oral rehydration techniques, breastfeeding, and immunisation. GOBI was later extended to GOBI-FFF (female education, family spacing and food supplements, respectively) by the mid-1980s. But CPHC remained more and more elusive.

As a middle course between CPHC and free market of health care, WHO championed the concept of “universal health coverage (UHC)” and “universal access to health care” – “The goal of universal health coverage is to ensure that all people obtain the health services they need without suffering financial hardship when paying for them.” Lancet observed – “The resolution and its UHC concept firmly and narrowly centre on health insurance packages financed through per-payment ... the clinical sector commonly tends to emphasise specialist curative over health promotion or preventive primary care.”

In the past two decades, powerful international trends in market-oriented health-sector reforms have been sweeping around the world. Global blueprints have been advocated by agencies such as the World Bank to promote privatisation of health-service providers, and to increase private financing – via user fees – of public providers. Furthermore, commercial interests are increasingly promoted by the World Trade Organisation, which has striven to open up public services to foreign investors and markets. Such attempts to undermine public services pose an obvious threat to equity even in the well-established social-welfare systems of Europe and Canada. The magnitude of this situation – known as ‘‘the medical poverty trap” – has been shown by national household surveys and participatory poverty alleviation studies. For example in India 52% of out-of-pocket health expenditure went towards medicines and fees, as did 71% of in-patient expenditure.

Unlike population at large, an individual patient is treated in a clinic or hospital for his “clinical’’ or individual health. One recent study observes, “Clinical teachers have been under intensifying pressure to increase their clinical productivity – that is, to generate revenues by providing care for paying patients. The present context of American medical curricula and clinical teaching, which heavily guide and influence Indian curricula, notices – “It is ironic that precisely when students can finally begin doing the work they believe they came to medical school to do – taking care of patients – they begin to lose empathy.’’ Possibly, out of such unprecedented developments, NEJM is compelled to ask – “Are We Living in a Medical Education Bubble Market?’’  One should understand that the philosophy and ontology of public health are fundamentally different from that of individual or clinical health. It demands a different kind of epistemological approach. Public health is an open space – there is nothing hidden in this curriculum. It comprises the heterogeneity of the population, their cultural and religious uniqueness, ways of living, and, moreover, social-embeddedness in countries like India, Pakistan or Bangladesh. A Well-trained medic is not necessarily a productive and dedicated public health worker. Good training in clinical courses does not automatically lead to becoming a good physician for public health programmes. Free market economy and the emerging new social psyche try to erase the distinction between these two health concepts.

 Dr. Jayanta Bhattacharya

Vol. 49, No.50, Jun 18 - 24, 2017