Global Health Watch 1 in one file

Health care systems | B1
• declines in real public health expenditure and increasing donor dependency;
• deterioration of health facilities and equipment;
• shortages of drugs and other supplies;
• dwindling patient attendance at public facilities as the quality of care worsened;
and
• a catastrophic loss of morale and motivation of public health workers as
the value of their salaries plummeted and as expenditure constraints undermined
their ability to work.
Demoralization, cynicism and unethical behaviour grew among public sector
health workers. This included treating patients uncaringly, levying ‘under
the counter’ charges, ‘moonlighting’ in the private sector and stealing drugs for
private use (Bassett, Bijlmakers and Sanders, 1997). Public sector downsizing
and resignations led to health workers migrating to the private sector, adding
to the growing numbers of informal and unregulated drug vendors, ‘pavement
doctors’ and other private practitioners. As public services deteriorated,
households resorted increasingly to over the counter drug purchases and the
use of private practitioners. While informal health care practice has always
existed in developing countries, this economic crisis resulted in its significant
expansion independently of any health sector reforms, a process that is called
‘passive privatization’.
The macro-economic crisis also had an indirect effect on health care systems.
It provided the IMF and the World Bank with an on-going opportunity
to intervene in and shape the health sector of poorer countries through structural
adjustment programmes and conditionalities attached to grants, loans
and debt relief.
Health sector reform, neoliberalism and the commercialization of health care
‘Health sector reform’ is the term used to describe a set of policies initially
promoted by the World Bank and IMF, often through structural adjustment
programmes, from the mid 1980s onwards. These have included imposing
tight and reduced fiscal limits on public health care expenditure; promoting
direct cost-recovery (user fees) and community-based financing; and transferring
or out-sourcing functions to the private sector. Later, the ascendance of
neoliberalism (Box B1.2) added an ideological impetus to the privatization of
health care. More recently, the World Trade Organization (WTO), together with
a number of bilateral and regional trade agreements (usually involving the
United States), have influenced the design of health care systems by reducing
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