I chose to address the issue of
financing health care. By comparing how the issue was addressed in the Global Health Watch 3, to a case study
written by medical anthropologist Ellen E. Foley, called Neoliberal Reform and Health Dilemmas: Social Hierarchy and Therapeutic
Decision Making in Senegal, I was able to better understand both the
economic and social implications of recent health financing. Both the Global Health Watch(GHW) and the case
study discuss the recent shift in health financing towards a market-based,
neoliberal structure and how this approach is ineffective in providing adequate
health care coverage, especially in low income countries. While the GHW provides necessary basic information
about the issue regarding the reasons for the reforms, and the logical reasons
why they have been detrimental, the case study allowed me to understand how a
neoliberal health financing system could lead to more subtle negative fallouts
due to its failure to fit with the social structure of various cultures. The
medical anthropologist perspective reminded me once again that even though a
structure might work theoretically, there are often factors of reality that fail
to be taken into consideration.
Summary of Issue as described by the
Global Health Watch
The chapter in Global Health Watch 3 titled “Financing
Health Care: Aiming for Long Term Solutions,” discusses how a wave of recent
health reforms that were initiated by the World Development Report of 1997 have
decentralized and fragmented health care. Without much support from the
government, these fragmented health care systems have become increasingly dependent
on outside aid for revenue. However, the problem with relying on aid is that it’s
inconsistent and, consequently, health care providers can’t rely on the
resources they need for primary health care services. Therefore, there has been “a recent shift from
comprehensive primary health care to selective primary health care” and
temporary, vertical programs have received more funding (GHW 2011:63). Also,
because aid is being received from so many different sources, systems are
overwhelmed by having to sort through all of it, causing aid delivery to be faulty.
The GHW puts forth that in order to
avoid dependence on aid, poorer countries must find a way to create revenue for
their own health care. As of now, the most common way low income countries are
doing this is by implementing user fees, an approach that was pushed by the
World Bank in the 1980s (GHW 2011:64). The supporters of this approach claim
that not only does it create revenue, but it keeps people from excessive use of
health services and creates a sense of individual responsibility. However,
according to the GHW, overuse of
health services is not a common issue, and user fees don’t actually generate
that much revenue. The GHW also rejects the neoliberal solution
of private health insurance stating that, “as these schemes are based on an
individual’s ability and willingness to pay, they lead to obvious inequality in
access, market segmentation, cream skimming, and exclusion of vulnerable groups”
(GHW 2011:68). The GWH contends that
the only system of financing health care that has the potential to provide
universal coverage, is a government tax-based system. While it is acknowledged
that a tax-based system is extremely hard to implement in a poor country where
the government may be in disarray or plagued with corruption, it is argued that
those other issues will need to be addressed regardless in order for health
care to progress. The GHW suggests that taxes be implemented in subtle
ways at first, so that they’re not unbearable for the public and eventually the
country can support its own health system.
Summary of Medical Anthropologist Article
Ellen E. Foley wrote this
ethnographic article based on 14 months of fieldwork she did in the Ganjool
region of the Senegal River delta from 1998-1999 and 2002 to 2005. Like the Global Health Watch, Foley discusses the
effects of the economic reforms encouraged by the World Bank in the 1980s and early
1990s. In this particular case, since the main source of income for most of the
population is onion farming, the decision of the state to build a dam and
sponsor commercial agriculture in the Senegal River Valley has been extremely
detrimental to the local economy because the farmers have lost much of their
land and are unable to compete with commercial farming. As a result, there is a
new trend in young men migrating to the coast to become fishermen hoping to make
more money and become financially independent. While that may seem like a good
thing, it greatly impacts the traditional social structure of the region. The
social structure of most communities in the Ganjool region is very much based
on gender and age. Households often consist of multiple families living
together with one man as the senior patriarch who is financially responsible for
those living under his roof. The patriarch has the power to make decisions
about the lives of those within his household. Therefore, many patriarchs feel
undermined by young men leaving the village in seek of independent wealth and
want to keep them under their control as contributing members of their
household. As we see in the three cases presented in this article, the
patriarchs are willing to go so far as to deny these young men health care to
reassert their authority. Thus Foley argues that, “intra-household power
relations are equally important for understanding the effects of macro level
economic transitions on health decision-making process, vulnerability, and
illness outcomes” (Foley 2008:260).
Not only have these changes in the local economy caused this power
struggle, but the government’s implementation of user fees has worsened the
problem. After the passing of the Bamako Initiative in 1987, user fees were
implemented for health services throughout Sub-Sahara Africa (Foley 2008:259). Foley
shows us through the cases presented in this article that while user fees
increase citizen responsibility in theory, they have hindered people’s access
to health care. For example, even though women are primarily responsible for
taking care of the health needs in the family, due to the social hierarchy, they
must ask permission of the patriarch when seeking any medical services that
involve a financial commitment and therefore often try to solve health issues with
ethno medicine to avoid cost and having to ask. On occasion they’ll even use
their limited amount of money to try and pay for the services they want so that
they can get around their husbands. If they didn’t need to pay user fees, they
wouldn’t have to go through their husbands and would have access to the care
they need for themselves or their family. But between people’s fear in asking
for financial help, and patriarchs often denying financial assistance, people
aren’t receiving the health care they need. Patriarchs would not have this
power over health care if people did not face the financial obstacle of having
to pay for health services.
Medical Anthropologist view compared to
Global Health Watch
Unlike the annual World Health
Organization Report, the Global
Health Watch (GHW) is not merely a compilation of statistics, instead it
provides analysis of current global health issues, and thus offers some of the
perspective of a medical anthropologist. It addresses the discrepancy between
the theoretical results of neoliberal reform and the reality of what happens
when that type of system is actually implemented in low income countries. While
the GHW provides us with a general
look at how health reforms are affecting people, it still lacks the ethnographic
approach that a medical anthropologist would use to look at an issue. Because
the GHW is addressing the issue of
health financing from a global perspective, it is analyzing the issue by
looking at the financial effects of policies and is unable to provide us with
specific explanations of why policy implications are or aren’t working on an
individual level. In a sense, the GHW makes
some of the same mistakes as the big actors they criticize by making general
assumptions about how policies are or aren’t working without gathering
information on social and cultural reasons for what’s happening. In comparing
the GHW chapter to the article by Foley,
we can see how, by taking yet a more in-depth look at these issues and
analyzing specific cases of illness within a society, we learn that there are
often issues unique to that society that might not have been realized without
further investigation. In Senegal, it turns out that not only are people unable
to afford user fees, their social structure is not set up in a way that
everyone can access health services that require a fee. I doubt that many
people would realize the complex reason why young men were dying in the Ganjool
region without having read some sort of close study like the one presented in
this article. It is interesting that there was no mention in the GHW about social structures, and yet
without that knowledge the heart of the issue might never have been realized.
My Thoughts
and Conclusions
From reading about the issue
from the perspective of a medical anthropologist, I gained a new understanding
of the concept we discussed in lecture: that “power is the determinant of
health.” I originally took power to be the government, or corporations or any organizations
that controlled resources that populations received. However, after reading the
article on Senegal, I realized how that concept is applicable all the way down
to the family structure. I learned how critical ethnographic study is to
realizing the subtleties of health crises. Cultures are based on collective
ideas and basic structures and people will cling to what they’re used to and
reject new implementations that are foreign to them. Therefore it is important
that policy makers are informed about issues from the perspective of a medical
anthropologist, so that they don’t miss social and cultural details that may
seem small in comparison to larger economic and political obstacles, but that often
end up being the reason why people aren’t receiving the care they need.
Policy makers have been
idealistic and narrow minded when creating health system reforms over the past
20 years. They’ve tried to stimulate the economies of low income countries by
implementing neoliberal reforms. However, they’ve failed to take into account
the social and cultural differences between western and non-western cultures. Market-based economics may have stimulated
growth in the western civilizations, but that doesn’t mean it’ll have the same
effect elsewhere in very different cultures and societies. Foley pointed out the
irony of what happened to the young men in Senegal who did what the reformers
were pushing for and sought financial independence, which they were then
punished for within the context of their own society. Therefore we can see how
it is important to take into account not only economic factors, but social and
cultural factors when trying to solve the issue of how to finance health care. A
medical anthropology perspective can help analyze competing strategies.
There is no denying the
difficulty of trying to find a solution for a problem that is tied to the
economic, political and social issues within a country. While health care
systems aim to provide for entire populations and are therefore handled on a
large scale, the success of the system depends
on how well it can provide for individuals. It is clear from both the Global Health Watch (GHW) and the
article, that free universal health care is the only way to ensure health care for
all. The GHW suggests a tax-based
financing system that will develop each country’s ability to support itself. However,
they do acknowledge that it is very difficult to begin implementing taxes in
such poor countries. So maybe instead of foreign aid coming to countries
through organizations focused on specific projects, it should go towards the
government of these countries to help them start developing nation-run health
systems. Some organizations have already shifted to this approach (Nichter and
Pfeiffer 2008:411). It’s true that in order to create a solid health system
within a country, the nation will be forced to deal with political and social
issues, but by paying attention to ethnographic study, organizations and
policymakers will have a better idea of what those issues are and be better
equipped to direct resources towards dealing with those issues.
-Carlie Anderson
References
Cited
Foley, Ellen E.
2008 Neoliberal Reform and Health Dilemmas: Social Hierarchy and
Therapeutic Decision making in Senegal. Medical Anthropology Quarterly
22(3):257-273
Nichter, Mark and James Pfeiffer
2008 What Can Critical Medical Anthropology Contribute to Global
Health?: A Health Systems Perspective. Medical Anthropology Quarterly
22(4):410-415
People’s Health Movement, Medact, Health
Action International, Medicos International and Third World Network
2011 Global Health Watch 3: An alternative World Health Report. New
York: Zed Books Ltd
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