By Marwaan Macan-Markar
MEXICO CITY, Nov 28 2000 (IPS)

While the world’s poor estimated at over a billion peoplecontinue to be deprived of basic health care services, a debate has emerged as to who should take the lead to prescribe a remedy the World Bank or governments in the developing world?

The Bank maintains that the governments should initiate action to reach the poor through effective basic health care services. “Strengthening health policies and programmes within any country is first and foremost a right and responsibility for the country itself,” says Davidson Gwatkin, a leading health specialist at the Bank.

“The most promising role for the Bank is to work with authorities in the countries concerned to identify and implement those programmes,” he adds.

But health experts in the developing world disagree, arguing that the Bank has both the financial muscle and the political clout to initiate change in countries that have been following the “development models” prescribed by the Bank.

“The World Bank should take the lead in this area,” asserts Bienvenido Alano, a ranking member of the Geneva-based Global Forum for Health Research and head of the Centre for Economic Policy Research, in the Philippines.

After all, he adds, “It is part of its mandate and it has the funds to make it happen, particularly in countries where leaders are willing to embark on such an exercise”.

According to Arjuna Aluwihare, on the other hand, the Bank cannot ignore the consequences of its structural adjustment programmes (SAPs) in the developing world that have led to the world’s poor being denied access to basic health care.

They have contributed to the current state of deprivation, argues Aluwihare, a professor of surgery at the University of Peradeniya, in Sri Lanka. “The Bank has to reverse some of its policies and consider (development programmes) in a holistic manner.”

This debate stems from a set of new reports released this month by the Bank that revealed the wide disparities between the health status of the rich and the poor in 44 developing countries.

As a result, the reports stated, children of the poor are dying of diseases in greater quantities than those of the rich, even if they inhabit the same country. A similar disparity exists when it comes to receiving care from trained medical personnel, where the richer citizens have ready access.

What prevails in Bolivia and Turkey illustrates this disparity, where “mortality rates among children under five years can be four times higher among the poorest children compared to the richest children”.

And in the countries of sub-Saharan Africa, less than 40 percent of the poorest children are fully immunised when compared with their counterparts from richer households, where close to 70 percent have been immunised.

Regards the poor being deprived of medical attention, the situation in Bangladesh is illustrative. “A rich woman in that country is over 15 times more likely than a poor woman to have a medically trained person (nurse, nurse-midwife, or doctor) present when she delivers a baby,” the reports noted.

The analytical approach used in these studies was geared towards “identifying the magnitude of poor-rich differences”, says Gwatkin, one of the authors of the reports.

They clearly show that “basic health programmes are not serving the poor well enough to close the inequality gap with the rich”, he adds.

Among the countries surveyed in these reports were 22 from Africa, eight from Asia, nine from Latin America and the Caribbean and five from Central and West Asia.

The Bank’s call, in fact, for a need to reverse such health care disparities comes in the wake of a similar call made by the World Health Organisation (WHO) this year.

The Geneva-based health body observed in a review of global health systems that access to basic health care services still remained a distant dream for a large portion of the world’s poor.

And in its diagnosis, it shed penetrating light on a pattern it found particularly disturbing in many developing countries the “profoundly anti-poor” culture prevalent in a number of health systems.

“The distribution of services is highly skewed towards the better- off, and that resource allocation, by default, hurts the poor,” the authors of the WHO report charged.

Such a bias, they added, was evident when one compared access to health care in the urban regions of countries as against that which prevails in the rural regions, where “there are more health professionals in the cities, while most of the poor live in rural areas”.

Consequently, deadly infectious diseases, such as the Human Immunodeficiency Virus (HIV) that causes Acquired Immune Deficiency Syndrome (AIDS) Malaria and Tuberculosis, “disproportionately affect poor people”.

For Gwatkin, the Bank’s hope is to use the findings in the reports for change. “The figures provided will constitute a helpful starting point for lessening the differences, regardless of who is to blame for them.”

And he contends that governments should take the lead in prescribing the most effective remedies for their respective countries. “The World Bank can help countries find and work towards a solution, but the lead will have to be taken by the countries if progress is to be made.”

Aluwihare, however, sees it otherwise. While conceding that governments do have a responsibility to secure better health care services for the poor, he insists that the Bank can specify priorities in public health programmes, like immunisation and mother and child-care.

Alano echoes a similar view. “In countries where institutions are so underdeveloped, they can hardly be expected to set proper priorities.”

Excerpt: