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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 experiences 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 mooring. It uses a
perspective wherein the health sector moves beyond the context
of market, 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
examining 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 neoliberal
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 they face 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
declining price of goods and a consequent fall in export
revenues were detrimental to economic growth. The first to f eel
the effect 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 grow, 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 end
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 WB 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
globalisedeconomy.. The other saw it as a step backward in the
region’s efforts at independence, self-sufficiency, and
building a less inequitous 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 institutions was initiated with their
full consent and collaboration. For example, in 1992 the World
Bank took the liberty of planning the health sector for India
(World Bank 1992). In 1993, it produced the World Development
Report on health, which was its blueprint for the Third World.
Instead of critically examining the report, it was used by a
majority of politicians, technocrats and bureaucrats as
guidelines for transforming national-level plans.
The
methodologies that evolved in the process were highhanded 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 an
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 a 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
deteriorated its terms of trade. Hence, the restructuring was
introduced much earlier, in the nineties.
In contrast,
Bangladesh, the youngest of all these 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 manner. 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 HDI
and literacy rate are the lowest, it is interesting that over
the past two decades investment in education and health has
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 and each state has a unique experience. As a country
though, while its per capita income 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 is Kerala with a lower economc
growth rate but high levels of social indicators and on the
other hand there is Haryana where the latter are low despite
better economic achievement.
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 offer various proposals to improve health services
in the current scenario.
With its many insights and
inner-disciplinary approach, this volume will sinterest all
those involved in community health, social medicine, sociology,
economics, public policy and social work.
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