Table Of Content

tact “ Ss oVM ° m A publication of the CMC-Churches’ Action for Health, World Council of Churches HEALTH FINANCING CRISIS © ommunitie oe affor e HEALTH FINANCING Crisis Pharmaceutical adviser no 146 2 Editorial Can Bamako help solve the crisis? December 1995 - 3 Health workers January 1996 ; Speaking up for the poor in Chile Resource materials 6 PHC administrator UPDATE Cost recovery can work! 16 Nuclear testing in the Pacific, 9 Programme manager Women and HIV: Beijing and India Questioning the “Robin Hood” approach NETWORKING 12 Programme director 19 Letters, Useful publications and When ducks pay the health bills Announcements EDITORIAL Earlier this year, Contact 141 Financing munity aspires. Nevertheless, he still Health Care described the changing maintains that in a caring society, the policy and thinking in health financing. state should be responsible for the main- We asked you to respond to the debate tenance of health as a right for all. about these changes from your local In contrast to the success in Cameroon, experiences. We were not disappointed. the experience in India (page 9) was In this issue of Contact, we provide different. Daleep Mukarji found that com- some of the many responses received munity cost-recovery schemes benefited from readers. | the rich to a greater extent than the The first article is an interview by Contact poor. Like David Werner, he cameto the reader Karen Anderson who works with conclusion thatit was vital to ensure that EPES in Chile. She and a colleague the service or project was the aspiration spoke to two health workers from the of a fully-participating community. urban squatter communities of Santiago Inthe Philippines, Carl Salem, who says about the effects of structural adjust- In India, community he has been reading Contact for many ment programmes (SAPs) and privati- years, felt that the only way to ensure cost-recovery zation policies on health care. World that the poor had the funds they needed schemes benefited Bank adherents claim that these policies to pay for health care was to create have been a great success in Chile. the rich to a greater source of reliable income. Now, all healt . These health workers think differently. bills are paid in kind — in ducks’ eggs. extent than the In particular, they say that poor com- poor. munities like theirs face declining public Finally, we provide an update on the - services as more and more privatization Bamako Initiative which aims to bring takes place. They cannot afford to pay - more money into local health services. for private health services as they are Although spreading worldwide, there expected to do, but they are not poor remain problems. High-risk groups are enough to be defined as “indigent” and excluded from services, there are risks therefore entitled to help. The reaction of over-prescribing, and in some cases, of these community health workers to community involvement is threatened their appalling situation is simply to by administrative burdens. strengthen their efforts to organize and We hope that these articles will prove to fight with the poor. be an inspiration to you. Do write and let The second article comes from a rural us know. We welcome your letters. setting in Cameroon. A primary health care (PHC) programme administrator says she disagrees with David Werner’s opposition to cost recovery (Contact 141, page 1-4). She says that her programme is able to recover costs in an pzt eh equitable way. In answer to her letter, m7 Z 5 David Werner says that cost recovery canbe benevolentif the service is some- J“i.oa ty s= thing to which an individual or com- o*Sox eee WsSs s =aSSt; ie == e “=>Na oy -D& =:aA o . P Tg8 ef COVER Peter Williams/WCC (eeECeyaeee e e 2 contact n°146 - December 1995-January 1996 . HEALTH WORKERS SPEAKING UP FOR THE POOR IN CHILE In this interview, two health : promoters trained by EPES (Educacion Popular en Salud) in Chile describe the effects of health reform in their communities. They say that the poorest communities find themselves paying more for fewer, poorer quality services. The asics eosin etinennean ane OLMEDLEOR E.DEL AEDS be women believe that the only way ahead is to continue to organize within their communities, and to speak up as often as they can on behalf of the poor. Introduction | The World Bank and other international financial institutions have presented Chile as amodel of economic and social reforms. The results of privatization, liberalisation and deregulation have received lavish praise in international circles. But from the perspective of the oor, it is crystal clear that access and ality of health services have seriously deteriorated. The first major decline in the quality of services began in 1973 when the military dictatorship of Pinochet came to power. After the coup, the military fired thousands of health professionals and health workers, and banned and perse- SaJArli/dgC ahdrois tian cuted members of the National Health Patchwork workshop in Workers Federation (FENATS). The Santiago, Chile reform process led to a cut in the health services for lower income workers on budget for the first time in decades. public funds. During the 1980s, primary health services began to be transferred In 1980, also on the recommendations to the municipalities, and in 1986, cost of the World Bank and IMF, the National recovery was introduced. Health Service (SNS) was dismantled and replaced by a set of private profit- With the return of a civilian, elected making enterprises (ISAPRES) and the - governmentin 1990, expectations were creation of the Fondo Nacional de Salud high for an improvement in the health (FONASA) which manages the health services. However, although health contact n’146 - December 1995-January 1996 HEALTH WORKERS expenditure has increased, World Bank- Unfortunately, one can appear on the ~ inspired policies are still being applied. computers as being registered but it As the crisis in primary health care might not necessarily be true. My sister- deepens, the poorer municipalities are in-law was able to find work last year particularly badly affected. Meanwhile, and so she was automatically regis- the Frei government and other World tered and had to pay for ISAPRES. But Bank policy advocates continue to speak she lost her job six months later and no The poor end up enthusiastically about the health reform longer has access to private services. lying in order process in Chile. The voices of those Nevertheless, she appears on their list to be able to mostaffected by these reforms are rarely of registered clients. obtain the right heard. Valeria: The majority of the people are to receive services. In this interview, Monica Maldonado only recently becoming aware of what. which are now and Valeria Garcia, health promoters has happened to the health services. trained by EPES who have lived all their They feel totally vulnerable - as if there reserved only for lives in the dusty, urban poblaciones | is no place to turn for help. Part of the the indigent. (poor communities) of Santiago, give complexity of this system is that there is their view of the changes. a new way of classifying poverty. For example, if you have an iron or a re- Question: How do people in your frigerator, you are no longer poor. Th neighbourhood understand the pri- poor end up lying in order to be able to vatization process of the National obtain the rightto receive services which Health Service? are now reserved only for the indigent. Monica: People understand that with Question: How were the services privatization, the possibility of receiving before the process of privatization adequate health services has gone. began? They are gradually losing what they used to consider their rights. Monica: Before, the State subsidised health care through the National Health For example, in this community, every- Service. There used to be free prenatal one has had to re-register at the public care, dental care, immunization, well- health clinic. This is because, officially, baby care, and so on. If you were poor our community is moving out of poverty. and needed hospital care, for example, Supposedly, because such a high per- you were guaranteed the same rights _ centage of this community is using and benefits as someone who could ISAPRES (the private sector), we can Monica Maldonado showing pay. There was not really a second- handicrafts which she and no longer be categorised as poor. class health system for “second-clasj— other health promoters make to support their work. citizens as there is now. Today, we are hearing about things in our neighbourhood which had not previously happened for many years. For example, there have been a couple of cases of women dying in childbirth inthe public hospital. That should not happen in the 20th century. And who responds? Nobody. Question: With so many problems ~ from your perspectives, why do you think the World Bank promotes privatization as a model of health care © for the developing world? | Valeria: Everything is looked at froman economic point of view, not fromahuman — point of view. From my perspective, EPES privatization is just one more way to line ve contact ‘146 - December 1995-January 1996 Pe HEALTH WORKERS _ the pockets of the rich. There seems to _ be a loss of conscientiousness globally intoef hurmanm lisfe a nd human beings. Everything is related to money and consumption. | Monica: | am worried about who makes these decisions and based on what evaluations. When is the voice of the people most affected by these policies ever heard and listened to?- Who has ever asked us what we think of privatization? When the National Health Service in Chile began the process of privatization, we were living in a dictatorship and were not informed of the changes. Pub- CAhirdi stian lic health workers and some sectors of Small girl near her home in an urban community in Santiago Be population resisted the privatization longer any sense of service —everything _ process but they were repressed by the is calculated according to its economic Pinochet government. Unfortunately, value. The ideals of service and solidar- because of all today’s one-sided hype ity in this world of consumerism are not -about the reforms and “modernisation”, valid. all change is seen as “progress” for the Part of our problem (with the present country. We never hear about develop- approach to providing health services) ment of people, we only hear about is that our concept of health is pro- economic growth. foundly related to life. Health means Valeria: Inadequate health care affects having work, education, adequate It has become common all aspects of people’s lives. Now that so housing, recreation, a clean environ- to hear of people many services must be paid for, it has ment, living without fear of government who have stopped become common to hear of people who repression, and the possibility of partici- have stopped eating so that they can pating actively in the policies and pro- eating so that they can afford to go to the doctor. We all know grammes which affect our lives. With afford to go to the that this just makes you more vulner- the current privatization schemes, not doctor. able to illness. Once people start dying only in health but also in education and <on the streets then maybe others will sit other services, we are moving farther up and take notice of whatis really going and farther away from “health for all” — on. not closer. Monica: We are all Chileans. We all As members of poor communities, we contribute to building this country. Having are used to organizing and fighting to access to adequate public health have our rights recognized. This situa- services is not asking for a hand-out - it tion is justa new momentin that struggle is a basic human right and we deserve for us. it. Interview by EPES staff members, Question: Do you think anything can Karen Anderson and Lautaro Lopez, be done about this situation? who also provided the introduction. Valeria: The main complaints that people have are related to the decreasing quality of the services. People feel so humiliated and frustrated by the inhu- man treatment they receive. Health professionals here used to be very con- scious of the reality of poor families — now itis all simply economic. There is no contact n‘146 - December 1995-January 1996 PHC ADMINISTRATOR \ LETTER FROM CAMEROON COST RECOVERY CAN WORK! While many blame the deterioration in a) As a community health initiative, the the health services on the World Bank’s programmeis self sustaining atv illage policies, Contact reader in Cameroon, level. It encourages and builds com- Mrs PA Mitchell of the Life Abundant munity independence in such a way Programme in Kumbo, was also critical that, should expatriate personnel have of the position taken by veteran health to leave, itw ould be possiblfeo r health activist, Dr David Werner. She wrote to care to continue. . say that contrary to the views he b) Because the “initiative” to have village expressed in “The build up to the crisis”, health care always and only originates © Contact 147, February-March 1995, she with the community, the idea of self had found that cost recovery could be funding and self determination is successfully implemented for the benefit built-in feature of the programme. of the poor. Here is herl etteri n response People therefore understand from the to Dr Werner's article. outset that all income to the Health Dear Dr Werner, Post will be used to benefit the community. The income covers the costs | am administrator of the Life Abundant of salaries, continuing education and Programme (LAP), acommunity health the maintenance and improvment of initiative in Cameroon, West Africa and equipment of Village Health Workers | should like to make a few comments and Trained (traditional) Birth Attend- regarding your article. ants. Salary levels of the VHW and Cost recovery systems TBAs are agreed at the village level. Our experience at LAP over a 15-year c) The Village Health Workers and the deriod has been that cost recovery is an members of the Village Health Com- acceptable practice and works well. TBAs in Rwanda learn to use mittee administer the locally-gener-_ leaves and roots to make ated funds. They are all local people age-old remedies that work in and are therefore able to judge with tandem with modern medicine. some accuracy those families wh€> absolutely cannot afford the cost of needed treatment. In such cases, they have the right and the resources to reduce costs or even to waive them completely if they see fit. However, in practice this rarely happens. Either - people are encouraged by the Com- mittee to pay in instalments, or - amethodof bartering goods is found for them, or - a formal appeal is made to the local church which may then help. In real- — ity, this is a less common option not because the church will not or does not want to help but because the people realise that once again this represents the dependence that they have tried so hard to avoid. DBeermtm ers/Unicef contact n°146 - December 1995-January 1996 PHC ADMINISTRATOR Nurses distribute drugs at the Methodist welfare clinic in La Saline, Port-au-Prince, Haiti. Taxation recovery. Only about 30% of salaries In some countries, the central govern- and costs of these qualified nurses is ment tax structure does not incorporate met by overseas funding agencies, and or is not adequate to support Health this figure is decreasing annually in real Care for All. If health is provided by terms. However, as the programme is outsiders or local agencies, there is the continuing to develop, there is an dependency that goes with it. Addition- increase in the overseas contribution in ally, in the many countries where the direct proportion to the expansion for system is corrupt, even funds raised to the time being. To-date funding agencies pay for drugs or treatment is frequently have agreed to underwrite this cost. ‘diverted, and overseas aid salted away Contrary to what you say in your article, in private bank accounts before it ever Only about 30% of the health centres find that as people’s wren’ those for whom it was intended. awareness of improved health standards salaries and costs svhere is therefore no practical alterna- - increases, so does the utilisation rate of these qualified tivetosome form of cost recovery system (UR). This is a finding of this year’s LAP if health care is to be truly indigenous nurses is met by Evaluation conducted by Bread for the and sustainable. overseas funding World. Targeting agencies. Thank you for the clear and concise In our programme, preference is not assessment of the Health Care situa- givenin any particular individual or group. tion in developing countries and factors Health care and teaching are offered on contributing to the difficulties that so a non-partisan basis to all. often beset primary health care in these While the Village Health Workers take countries. responsibility for maintaining continu- Mrs P A Mitchell SRN RMN ous teaching and care in their com- LAP Administrator munities, qualified nurses make support The Life Abundant Programme visits to their group of posts and conduct PO Box 9, Kumbo, NW Province vaccination and referral clinics. Funding Cameroon, West Africa for these visits comes from the larger We forwarded Mrs Mitchell's stimulating Integrated Health Centres and Hospi- letter to David Werner and asked him to tals. These bigger centres are also send us a copy of his reply to her. funded to a large extent through cost Please turn over. contact n‘146 - December 1995-January 1996 PHC ADMINISTRATOR The following are extracts from David lective provides a helping hand to its Werner’s response. individiuna tlimses of hardship orillness. In some cases, this group or collectivei s Dear Mrs Mitchell, the extended family, in others the community, in some cases the district, prov- Thank you for your letter. Many of your ince or state. As societies have evolved points are well taken. You do well to to large nation states, cost sharing has emphasithzate i n your health community become formalised through progressive programme in Cameroon, cost sharing taxation. Those who have more are has been successful and is conductive asked to help more in ordert o help meet to self-reliance. To a greater or lesser the basic needs of those who have less. extent, this has been true of many self- This ensures that the maintenance of determined, non-government grassroots health is a basic human right. programmes. We are all in favour of self-determina- What needs to be clarified is that “cost tion and shared responsibility. Certainly, sharing” can be either benevolent or each individual and family should be malign, depending on whether it is initi- encouraged and helped to take the ated from the bottom up or imposed primary responsibility for their own. from the top down. When itis something health. But part of that responsibility C2 that a person aspires to, either individu- In a humane, caring not just paying for health services. It ally or collectively, then it can be society, the larger group potentiating. When it is something also involves joining together in an organized demand for the social condi- or collective provides a imposed in order to shirk responsibility, tions and public services that make helping hand to its and as a denial of human rights, it can health and self-reliance possible, not be oppressive. individuals in times of just for oneself but for all. To make self- In a similar experience to your own in hardship or illness. reliance possible and sustainablfeor all, Cameroon, | have been involved for we must be sure that land, wages, many years in acommunity initiative run employment and education— and social by local villagers in the mountains of guarantees in times of need or emer- Mexico. For better and for worse, most gency — are fairly distributed. In a just of the health care people receive is what society, people can be asked to pay they manage to provide or pay for them- their share of the costs when they are selves. As in many countries where assured their share of the gains. governments administer inadequate | think that basically there is much we | basic health services to those in greatest agree upon. | thank you for your lettez- need, community-level initiatives must relating your experience calling on m do their best. Under such circumstances, to try to clarity the issue more clearly. families, neighbours and members of Keep up the good work. the community try to help each other David Werner — and share costs in times of need. But HealthWrights this sort of benevolent “cost sharing” is Workgroup for People’s Health and quite different from the current heavy- Rights handed global policy of imposing cuts in 964 Hamilton Ave health budgets, and making poor people Palo Alto pay for services that were previously CA 94301, USA covered or subsidised by the state. Worse still, this increased burden on the poor comes at a time when real wages are falling, when landlessness and unemploymentare rising, and when the gap between rich and poor Is widening. One way or another, people necessarily This drawing, which appeared contribute to the costs of health care; in David Werner’s book that is to say “cost sharing”. Inahumane, “Where there is no doctor’, has become his trademark. caring society, the larger group or col- 8 contact n'146 - December 1995-January 1996 — PROGRAMME MANAGER QUESTIONING THE “ROBIN HOOD” APPROACH Daleep Mukarji, former general secretary of Christian Medical Association of India (CMAI) and now working with World Council of Churches, has managed several major health programmes through periods of financial crisis. Here he ® describes the difficulties that he _ faced when he adopted the Robin Hood* approach of raising money from the rich to pay for health services for the poor. He concludes that if the rich are not to benefit more than the poor, the primary objective of community financing initiatives must be community involvement and serving the needs of the poor. Like many other non-governmental organizations (NGOs) involvedin health care, church-related hospital and com- unity health programmes find it increasingly necessary to raise funds and reach some level of self-reliance. My experience comes from an involvement in a community health and rural development programme in India in 1970s. We decided that we wanted to raise funds in the community not only PHaaurlr ison/WHO because we needed this money but Practitioners of traditional ~ also because we believed that some curative care given at the base hospital medicine have always charged for their services. contribution and participation from the and those who could pay and travel to communitwyas important. People would the hospital benefited most. The poor value our services if they paid even a did not benefit. They could not take time small contribution. off to travel to the hospital, and did not First, we introduced fee-for-service. Our have the funds even to pay for registra- staff and health volunteers knew the tion. We subsidized essential antenatal community and therefore were able to and child health services in order to grade charges, raising more funds from make them more widely available. How- * Robin Hood was an English those who could afford to pay higher ever, we were still not able to reach the forest outlawin the Middle Ages who stole from the rich to give fees. However, the fees only covered whole community. to the poor. ‘contact n’146 - December 1995-January 1996 PROGRAMME MANAGER WHAT ARE THE INCOME-RAISING OPTIONS? Community contributions Donor agencies | - donations from local charitable Itis importantt o be clear from the start organizations and from churches, that donors have their own priorities, local clubs, industry, philanthropists pressures and policy guidelines. Many and wealthy community members. NGOs have felt forced into Donations can also be made in kind. programmes designed to fulfil the fee for services in which payments standards and reporting requirements are made directly by patients/bene- of donors. ficiaries for services. The entrepreneurial approach prepayment schemes, including .a Some of the tried and tested options variety of community-based health include: insurance schemes. a) Income generating schemes, such: health tax/community levy is poss- as renting or leasing part of their ible where all are involvae ddefiinne d land, buildings and equipment in community and where there is an. order to produce an income. acceptable community leadership. b) Soft loans and special assistance fundraising schemes, such as pub- from banks and financing agencies lic entertainment shows, lotteries and to pay for profitable ventures. subscription drives. _c) Providing health schemes so that Government grants local industry can offer health NGOs should avoid becoming overly services to employees. dependant on their government. It is d) Endowment funds also worth remembering that many NGOs spend much time and money e) Specialised services by hospital coming to grips with the government and programme staff such as bureaucracy and then still do not offering training courses and receive their grants regularly. consultancy. Governments may also assist NGOs f) Building trustee support among in obtaining funds and supplies from those who are members of the Unicef, WHO and other international church, trust or group which owns agencies. or runs the NGO health project. Community insurance We had great difficulty explaining the We therefore initiated a community scheme and persutahe dlocialn pegopl e © health insurance scheme with which we of its value. They wanted to see how hoped to cover the costs of preventive those who joined fared before enrolling health services. This prepayment health themselves. Many of those who paid insurance scheme was drawn up in the full fee (US$1) could have afforded consultation with several community more. When they needed services, they — leaders. We emphasised that the were not charged. Others, who had not payment would be voluntary and related paid the contribution, were charged. to ability to pay and would cover the They tended to be the poor who had no preventive care of women and children spare cash but were more in need of below the age of five years. services. We began to feel that we were 10 contact n°146 - December 1995-January 1996 ©