Interview with David Sanders, one of the founders of the global public health movement. By T.K. RAJALAKSHMI
DAVID SANDERS, Professor Emeritus and founding Director of the School of Public Health at the University of the Western Cape (UWC) in South Africa, is a specialist paediatrician with postgraduate qualifications in public health. One of the founders of the global public health movement, he has over 30 years’ experience in health policy and programme development in Zimbabwe and South Africa, having advised governments as well as organisations such as Oxfam, the World Health Organisation (WHO), the United Nations Children’s Fund (UNICEF) and the Food and Agriculture Organisation (FAO) in the areas of primary health care, child health and nutrition, and health and human resources. He has published extensively in these fields as well as on the political economy of health, including on structural adjustment and development. He has authored or co-authored three books The Struggle for Health: Medicine and the Politics of Underdevelopment, Questioning the Solution: the Politics of Primary Health Care and Child Survival and Fatal Indifference: The G8, Africa and Global Health, over 30 chapters and monographs and over 100 articles in peer-reviewed journals.
He was on the Steering Committee of the United Nations Standing Committee on Nutrition from 2002 to 2006 and a member of the Knowledge Network of the WHO Commission on Social Determinants of Health. He is on the Global Steering Council of the People’s Health Movement, was a managing editor of Global Health Watch 2 and a contributor to the recently published Global Health Watch 3. Excerpts from an interview he gave Frontline while on a visit to India on the invitation of the Delhi Science Forum:
You have written and spoken on the crisis in global health in the context of neoliberal globalisation. How have things changed since the 1990s? You said there were improvements in some health indicators.
I think the mid- to late-1970s was when primary health care was first elaborated as a new approach to health. It was around the late 1970s that development policy was progressive, not socialist but had a strong social democratic influence. I remember initiatives like the Brandt Commission [set up to study global development issues, it produced two reports that stressed the interdependence of the wealthy industrialised North and the poorer South] questioning the new economic order. That was the context that framed the emergence of primary health care and strategy.
However, very soon after the Alma-Ata declaration of 1978, structural adjustment programmes were initiated in response to the debt crisis of the mid-1970s; Margaret Thatcher came to power in the United Kingdom; Ronald Reagan in the United States; we had the Friedman School [of Nutrition Science and Policy] and the emergence of a combination neoliberal economics. So this combination of structural adjustment that affected continents had a major negative impact on countries especially in the implementation of primary health care.
It was during the 1980s that there was a lot of forced fiscal stringency in many countries. At the time this was happening, there was a split in the primary health care movement. A fairly influential paper published in 1979 appealed to a very important segment of global policy health makers. It was called selective primary health care. This suggested that implementing comprehensive health care entailed not just focussing on basic essential health services but also on addressing the social determinants of health. This project was treated as infeasible for the short term and as very expensive; there were also some crude attempts in the paper to cost primary health care. They called for interim measures to deal with primary health care.
This selective primary health care at that time focussed on a few high-impact interventions which could be relatively easily delivered even if health systems were not very well in order. There was a big push by UNICEF, WHO and other U.N. agencies. For example, immunisation improved to 80 per cent globally. But with the continuing economic crisis and the emergence of neoliberal thinking and HIV [human immunodeficiency virus] in the 1980s, a move was made to reform the health sector. This was very influential. The World Development Report in 1992 called for more cost-efficiency in health services and the privatisation of a few interventions. But it still neglected addressing the social determinants.
The health sector reforms included decentralisation of management and involving the private sector in health care financing and even health care delivery. That ushered in a new set of policy changes from the early mid-1990s. The fact was that countries were not investing in health, and U.N. agencies were less influential and less funded.
There was a call for PPPs [public-private partnerships] in health and they took the form of Global Health Initiatives. These GHIs are of different kinds. Some of them fund specific interventions and specific technologies and they bring in the private sector to benefit. There is the case of Unilever which is involved in a PPP initiative of washing where soap and other sanitary products are involved.
Then we have GAVI [Global Alliance on Vaccines and Immunisation], funded by the government of Norway and the Bill and Melinda Gates Foundation. This initiative funds the marketing and distribution of vaccines in developing countries. The private sector was very happy because there wasn’t as big a market for vaccines as there was for antidepressants and blood pressure medicines. So introduction of these GHIs as a new kind of funding mechanism aggravated the tendency to fragment the whole health system, making it very difficult for governments, especially poor governments, to implement their own policies, which were driven by donor funding. So, unsurprisingly, the health systems are not really as robust as they need to be in order to deliver all of the effective technologies that we’ve had, and addressing the social determinants of ill health have been neglected. We find that sanitation and water supply haven’t improved, chronic malnutrition and under nutrition are problems, and now we have obesity due to a change in food trade and consumption patterns. There have been improvements in general, life expectancies have increased, and reduction in child and maternal deaths has occurred. But in some parts, there has been a drop in life expectancy such as in countries that constituted the former Soviet Union. But the inequalities in health between rich and poor countries and within rich and poor countries have widened. These are a reflection of the inequalities of wealth.
Of late, there has been a growing tendency to look at the social determinants of health though this concept is as old as the Alma-Ata declaration. One sees that while there is a lot of rhetoric on social determinants, there is an attempt to look at them yet again with a fragmented vision. For instance, the disproportionate importance given to sanitation. This is not necessarily accompanied by an increase in health budgets.
I don’t think sanitation has received that much attention or investment. There is increasing attention to nutrition. But the way nutrition is being addressed is worrying. There is this initiative called Scaling Up Nutrition, or SUN, in common with GHIs I mentioned earlier. It calls upon global PPPs to address the nutrition crisis. The great majority of interventions are medical and technical. They do not address the structural causes of food insecurity. They promote interventions such as monitoring and promotion of food practices, breast feeding and food supplementation, all of which are effective interventions but do not address the deteriorating food security which is a reflection of the liberalised economic order. Many countries have had to open their borders and take in a huge influx of food and agricultural products coming from the global North. In every country we see that the health indicators for the richer segments are very good. So it can be achieved within countries. The food that is coming is highly processed food, coming either as imports or as FDIs [foreign direct investments] in subsidiaries of big transnational companies, which then produce and package these processed foods in developing countries. There is an increase in the purchase of processed food. There is a lot of noise about sanitation but no investment because there is no market. The rich have got sanitation and are connected to big systems but the poor have to purchase sanitation.
There is a worrying initiative, worrying to me at least. It is called the community-led total sanitation programme of UNICEF. It consists of getting communities to identify whether and where open defecation is taking place, and then by a combination of educating, imparting awareness and, worse still, shaming them, it is putting pressure on everyone to build their own latrines. So when UNICEF asks the states what their responsibility is in this regard, their answer is that experience shows that if you provide for people they won’t look after their latrines. It is letting the state off the hook.
The crisis is one of health inequity today. I suppose it is a crisis in a sense we know what can be achieved. In every country, the health indicators for the richest sections are very good. So it can be achieved within countries. It is not to say that every state can also have the same statistics as Japan. The crisis of emerging diseases, like the non-communicable diseases related to change of diet, are linked to globalised capitalist economy and liberalisation of trade and investment. The problems have to be addressed at global and local levels.
Is there a link between economic growth and well-being? It has been seen that it does not translate to distribution automatically.
There is a link but not a constant and direct link. A country like the U.S., which has the highest gross domestic product per capita, is a poor performer in health, while Costa Rica, which has a low GDP per capita, has the same kind of statistics as the U.S. Equity and focus on public services and social development are more important than wealth.
For example, in countries like Costa Rica and in your own Kerala State, there are a number of interventions that have led to improved health, like female education and female literacy, and this has led to changes in health behaviour that influence fertility, child care, etc. In the U.S., which is a very wealthy country and has a highly privatised health system used by people who are already better off, have better diets, and so on, ill health mostly affects the poor who are unable to access the services. In general, the wealthier the country, the better the life expectancy, but there are many exceptions and variations within that. The key variant is to create equality.
Everyone now seems to be talking about universal health coverage. It is as if it has been discovered all of a sudden, but there seems to be a qualitative difference.
It is being perceived in a much narrower sense, even by those who dominate the debate. The dominant discourse at the moment is financial coverage, not geographical coverage in services, access to them or quality. The idea is to cover people to access services. There are ways of doing this. There is the public, tax-based systems that the People’s Health Movement has been arguing for, but there is a strong push from private health insurance companies on public health systems to purchase private services.
On the one hand, one welcomes the focus on universal health coverage, but it is important to see how exactly it is defined and how it will be achieved.