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Chapter: Sociology of Health : Health services

Four Assaults on Primary Health Care

1. Selective Primary Health Care 2. Structural Adjustment Programs 3. World Bank’s takeover of Third World Health Policy 4. The Mcdonaldization of WHO and UNICEF

Four Assaults on Primary Health Care:



1. Selective Primary Health Care

– introduced in the late 70’s. The comprehensive approach to PHCwith its emphasis on equity and its call for a model of socioeconomic development conducive to Healthfor All,was quickly undermined by experts at John Hopkins School of Public Health, who claimed it wastoo complex and too costly. Instead, they advocated Selective Primary Health Care, focusing on a few “cost effective”, topdown technological fixes “targeting” high risk groups. UNICEF quickly adopted this selective approach, which in practice focused mainly on oral rehydration therapy and immunization. While these socalled “twin engines” of the Child Survival Revolution did succeed in somewhat reducing child mortality, they did discouragingly little to reduce poverty, hunger, or children’s quality of life. For this, a comprehensive approach is needed that confronts the root causes. While progress inimplementing the PHC strategy in most low and middle income countries (LMICs) has been greatest in respect of certain of its more medicallyrelated elements, the narrow and technicist focus characterizing what has been termed the ‘selective PHC’ approach (Walsh and Warren 1979) has at best delayed, and at worst undermined, the implementation of the comprehensive strategy codified at AlmaAta. The latter insisted on the integration of rehabilitative, therapeutic, preventive and promotive interventions with an emphasis on the latter two components. Selective PHC (SPHC) took the form in many LMICs of certain selected medical – mostly therapeutic and personal preventive – interventions, such as growth monitoring, oral rehydration therapy (ORT), breastfeeding and immunisation (GOBI). These constituted the centrepiece of UNICEF’s 1980s Child Survival Revolution, which, it was argued, would be the ‘leading edge’ of PHC, ushering in a more comprehensive approach at a later stage (Werner and Sanders 1997). The relative neglect of the other PHC programme elements and the shift of emphasis away from equitable social and economic development, intersectoral collaboration, community participation and the need to set up sustainable district level structures suited the prevailing conservative winds of the 1980s (Rifkin and Walt 1986). It gave donors and governments a way of avoiding the fuzzier and more radical challenges of tackling inequalities and the underlying causes of illhealth. Some components of comprehensive PHC, especially the promotive interventions, have remained marginalised ever since AlmaAta. These require for their operationalisation the implementation of such core principles of PHC as ‘intersectoral action’ and ‘community involvement’, and, increasingly with economic globalisation, intersectoral policies to address the social determinants of health (SDH) (Sanders et al. 2009). PHC has been defined (even in the AlmaAta Declaration) as both a ‘level of care’ and an ‘approach’. These two different meanings have persisted and perpetuated divergent perceptions and approaches. Thus, in some rich countries and sectors, PHC became synonymous with first line or primary medical care provided by general doctors, and simultaneously PHC has been viewed by many as a cheap, low technology option for poor people in LMICs. The AlmaAta Declaration was one of the last expressions of the development thinking of the 1970s where the nonaligned movement declared its commitment to a ‘New International Economic Order’ (Cox 1997) and a ‘Basic Needs Approach’ to development. These visionary policies were buried in the 1970s debt crisis, stagflation, and the dominance of global economic policy by neoliberal thinking. This, together with rising unemployment and changes in the labour market, changes in demographic and social trends, and rapid technological advances with major cost implications for health services, has, over the past two decades, driven a process of ‘health sector reform’ in industrialized countries and LMICs.




2.  Structural Adjustment Programs

introduces in the early 1980s. In the 1960s and 70s thegovernments and banks of the North loaned a vast amount of money to poor countries in the South to promote a model of development that replaced rural peasants and urban workers with fossil fuel consuming machines. This brought large profits for foreign investors and massive joblessness and increased poverty for the many. When poor countries began to default on their loans, the World Bank and IMF stepped in with bailout loans. There were tied to structural adjustment programs (SAPs). These required debtburdened countries to reduce public spending, including that for health and education, to free up money to keep servicing their debts to the Northern Banks. Whereas the Alma Ata Declaration has called for increased government spending on health, SAP’s pressured the poor countries to reduce and privatize public services. “Cost recovery” schemes (with introduction of “user fees”) placed health services out of reach for many poor families. As a result in some countries child mortality, sexually transmitted diseases and rates of tuberculosis drastically increased. In terms of the pursuit of Health for All, this was a giant step backwards.


3. World Bank’s takeover of Third World Health Policy 

in the 1990s. Prior to the 1990s the WorldBank invested almost nothing in health. But in the 1990s the Bank discovered that poor health reduces worker productivity, thus impeding economic growth (of big industry). So over a few years the Bank increased its investment in health to where, by the late 1990s, it was spending on the health sector three times as much as the entire WHO Budget. In terms of guiding Third World health policy, this has relegated WHO to second place, not only because of the Bank’s greater spending, but because it can tie its health reform “recommendations” to urgently needed (or strongly desired) loans. In its 1993 World Development Report, titled Investing in Health, the Bank spells out its health policy recommendations. These are essentially a free market version of selective health care. Governments should determine which health interventions to support according to their cost effectiveness in terms of keeping workers on the ob. Persons who cannot contribute to the economy – such as elderly and severely disabled persons – are ranked as of lower “value” and therefore merit little or no public assistance. Another dehumanizing step backwards in terms of Health for All!



4. The Mcdonaldization of WHO and UNICEF

–in the 2000’s. Partly because of shortage of funds,and partly because of influence of corporate gifts, in the last few years both WHO and UNICEF have entered into an increasing number of “partnerships” with transnational corporations, including drug and junk food companies. An example is UNICEF’s recent plan with fast – food giant, Mcdonalds. On its promotion McDonalds will include UNICEF public helth messages and boost sales of Big Macs by announcing that part of the purchase price goes to UNICEF. In Nigeria UNICEF has made a similar agreement with Coca Cola. Such compromises with industries that promote conducive to obesity, heart disesases, stroke and diabetes are not conducive for Health for ALL. Partnerships with other pre packaged massproduced food with endorsement by WHO or UNICEF. Even if these costly foods have improved nutritional content, they are still a threat to health. If poor families spend their limited money to buy them rather than cheaper staple foods (like Maize and beans), the end result is more undernourished children. The Alma Ata declaration called for combating the underlying social and structural causes of poor health. To the contrary, these new partnerships by UNICEF and WHO with transnational corporations further entrenches and legitimizes the forces that put healthy profits before people.



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