Sunday, January 20, 2002		Books

IMF and public health
Review by Uma Vasudeva

Public Health and the Poverty of Reforms: The South Asian Predicament edited by Imrana Qadeer, Kasturi Sen and K. R. Nayar.

STRUCTURAL Adjustment Programmes (SAP) as devised by the World Bank and the International Monetary Fund (IMF) were introduced in South Asia only in the early nineties. The first phase of these reforms in the health sector predicted differentiated effects for the region. However, as their basic thrust became visible over time, the negative consequences appeared to be uniform. This was particularly evident when the cutbacks in the welfare sector began to impinge on the growth.

When the countries of South Asia freed themselves from the grip of the colonial rule to reshape their destiny, they adopted a two-pronged strategy toward development. One component was the use of structural reforms at the social level. These included land reforms, protective legislation for the vulnerable religious and caste groups, provision of education for all and building of infrastructures to provide basic services such as public health (including medical care), transport, electricity, housing and drinking water.

The other component was the promotion and the use of technology to increase the outputs in all areas of primary, secondary and tertiary production. These two legs of developmental strategy were used in different combinations by various countries depending upon their specific context and political formation.

This volume studies the impact of SAP in South Asia and the myriad factors responsible for the state of public health in the region. It presents theoretical critiques of reforms in the health sector combined with fresh macro and micro data, which offer insights into public health issues. It brings together original essays by a diverse range of scholars, practitioners, and activists from India, Sri Lanka, Bangladesh and Pakistan besides bringing in experience from Europe.

This book is an attempt to look at the health sector in South Asia in a global context. It moves away from the prevailing neoclassical framework of analysis of health sector reforms to look at the health sector through epidemiological, health and social sciences, rooted in alternative theoretical moorings.

It uses a perspective wherein the health sector moves beyond the context of markets, medical technologies and overpopulation and takes into account social processes born out of conflicting and complementary economic, political, social and cultural realities. The focus is on complexities and processes and on unraveling the internal and external linkages of the health sector in order to draw attention to the challenges of the health planning in South Asia.

The book is divided into six sections. The first provides a conceptual and historical background linking the ascendance of neo-liberal economic policies with the practice of public health. The second examines the evolution of specific policies within the global context and shows how they are largely divorced from the needs of the people. Section three focuses on the changes in approach to both programmes and financing. The contributors demonstrate that this has entailed a shift from a broad public orientation to one which is vertical and technologically centred. The fourth section discusses the experience with decentralisation in the provision of services. In section five, practitioners discuss the growing dilemma that faces them in their practice of public health. The final section presents case studies of community based social development and employment programmes.

After the first oil crisis of 1973, the international market started putting pressure on the Third World countries by restricting entry of their goods and introducing restrictive monetary policies. The falling prices of goods and consequent fall in export taxes and revenues therefore were detrimental to national economic growth. The first to fall were the nations of Latin America followed by those of Africa. The South Asian countries were not far behind. Their external debt burden continued to rise as did their acceptance of the debt management strategies of the eighties.

In 1997, the total external debt of the developing countries was $ 2,173 billion and of the South Asian region $ 150 billion. Of this, India accounted for $ 94 billion. India’s external debt at the end of September, 1999, stood at $ 98.87 billion.

Refusing to deal with the structural issues underlying these inequities, the governments of these regions approached the IMF and the World Bank for support and sustenance. There were two basic responses to this official acceptance of structural adjustment policies. One lauded the step as bold and desirable and necessary for South Asia’s successful entry into the 21st century and its globalised modernity. The other saw it as a step backward in the region’s efforts at independence, self-sufficiency and building a less iniquitous society.

Given the long history of political, cultural, and intellectual colonisation, winning over the ruling classes was easy. The dismantling of the existing structures and institutisons was initiated with their full consent and collaboration. For example in 1992, the World Bank took the liberty of planning the healthy sector for India (World Bank rseport, 1992). In 1993, it produced the report World Development Report on health, which was its blueprint for planning for health in the Third World. Instead of critically examining the report, it was used by a majority of politicians, technocrats and bureaucrats as a guideline for transforming national-level plans.

The methodologies that evolved in the process were high-handed and manipulative. For instance, tools such as Disability Adjusted Life Years (DALYs) were invented to replace those based on years of public health experience.

Ritu Priya in one of the article explained how the data were distorted to accommodate vertical programmes such as AIDS. Imrana Qadeer has brought out that the evaluation of new strategies was not only conceptually and methodically flawed but was often avoided – as in the case of higher efficiency claims for private sector hospitals, which were never actually evaluated for coverage as well as effectiveness. Rama V. Baru has similar views that the evaluation of the private hospitals pertaining to public health was faulty and distorted. In addition, it helped to always look at achievements and to never address the implications – such as the side-effects of technology-based intervention (Richter) or the structural changes involved in opening up public sector hospitals to private investment (Evans).

All the South Asian countries have developed a variety of infrastructure, basic production systems, social and political institutions, class structures and conflicts, and the pattern of social sector development. While Sri Lanka invested the most in its social sector and has demographic indicators comparable to advanced countries, its slow economic growth over the sixties forced its terms of trade to deteriorate. Hence, the restructuring was introduced much earlier in nineties.

In contrast, Bangladesh, the youngest of all the countries, with a military bureaucratic structure right from its inception in 1971, depended heavily on external aid. Only from 1980 did it start investing in its social sector in a viable fashion. Pakistan on the other hand has the highest GDP and per capita income in South Asia, yet in terms of literary rate, demographic indicators, and human development indicators (HDI) it fares poorly.

While Nepal is among the poorest of countries and its HDI and literacy rates are the lowest, it is interesting that over the last two decades inputs in education and health have improved and there are small pockets with better achievements in both. Its infrastructure however, is weak.

In contrast to these relatively smaller countries, India presents a picture of diversity wherein each province has a unique experience. As a country though, while its GDP is less than that of Pakistan and the proportion of population below the poverty line much higher, its social sector indicators are comparatively better. On the one hand there are states like Kerala with lower growth rates but high levels of social indicators and on the other hand there is Haryana where the latter are lower despite better economic achievements.

Overall, this volume constitutes a comprehensive examination of public health practice in the framework of the ongoing economic reforms in South Asia. Apart from delineating various conceptual and methodological issues underlying the economic reforms, the contributors present various options to improve health services in the current scenario.

With its many insights and its inner-disciplinary approach, this volume will interest all those involved in community health, social medicine, sociology, economics, public policy, and social welfare.