Development cooperation and
Eventually, the Rockefeller Bank strategy, as it is referred to in Walsh and Warren's 1979 article, was adopted by UNICEF and the USAID before being taken over by the World Bank and the WHO in 1989. This strategy was laid out in the following publication.
Walsh J. A. and Warren K. S., 1979, Selective primary health care: an interim strategy for disease control in developing countries NEJM, 301 (18), pp. 967-74 https://www.nejm.org/doi/full/10.1056/nejm197911013011804
Its authors deemed PHC unaffordable and advocated that governments replace clinical care with public health programs in public services in LMICs. These services would henceforth be limited to disease control interventions and risk control by abandoning health care to the commercial sector and NGOs.
This has been the core of the International health policy doctrine for more than thirty years and it remains so : allocating public health programs to public services and individual and personal care to the commercial sector, thereby disintegrating disease control and clinical medicine. In 2007, based on a gray literature review , we concluded that in 15 years, all bi and multilateral had ended up adopting policies limiting the function of public services in LICs to disease control. and attributing the provision of individual health care to commercial services.
De Paepe P., Soors W., Unger J.-P. International aid policy: public disease control and private curative care? Cadernos de Saude Publica 2007; 23(Supp. 2): S273-281.
But coups d'etat are on the rise in Africa. In Latin America and Europe, the far right is on the lookout. It is time for cooperation agencies and democratic parties to understand the immense potential for social and political stabilization that lies within a health system that responds to the population's demand for care and cultivates medical professionalism. It is time for economic circles to understand how their interests can diverge from those of the insurance banks that invest in health.
Efficiency of international health policies
In 1985, there were already good reasons to doubt “Selective Primary Health Care”, the baptismal name of the Rockefeller Foundation strategy. But it was promoted by powerful economic interests. The cost of primary care services providing individual health care and disease/risk control was similar to frontline services providing only a few public health programs.
Unger J.-P., Killingsworth J. R. Selective Primary Health Care: Methods and Results. Soc. Sci.Med. 1986; 22: 1001-1013.
Also in 2008, we analyzed why low funding of health services was not sufficient to explain why maternal mortality stagnated at unacceptable levels in LMICs, and why it was also necessary to blame the replacement of clinical care by public health programs. in LMIC public services.
Unger J.-P., Van Dessel P., K.Sen, De Paepe P. International health policy and stagnating maternal mortality. Is there a causal link? Reproductive Health Matters, 2009, 17 (33):91-104
In 2008, we studied how 120 public/private global health initiatives were extended from the world capitals to the smallest African villages (57 such programs in Congo only). Despite a discourse stressing prioritization in disease control, the international cooperation agencies had created the biggest ever bureaucracy – ironically on the basis of efficiency claims.
J.-P. Unger. How could disease specific programs strengthen health systems delivering comprehensive health care? Strategic and technical guidelines. European Commission, DG DEV, 30 Sept 2008, Brussels
The cost of losing access to clinical care
For more than 30 years, development aid policies replaced clinical health care with public health programs in public services in recipient countries. Medical cooperation has simply disappeared. After 30 years of evaluating these policies, we can safely say that they have dramatically reduced access to care and the quality of care in LMICs without disease control programs succeeding.
Thus, the Millennium Goals were not achieved in the only continent where they would have represented a breakthrough : Africa. Preventable death and suffering have increased. The health sector generated political instability in low-income countries and, sometimes, contributed to make them failed states. Besides, international health policies also contributed to international migration, which European and American citizens seem to fear so much.
International Health and Aid Policies. Editors: J.-P.Unger, P.De Paepe, K.Sen, W.Soors. Cambridge University Press, 2010 (275 pages).
(Review in the Journal of American Medical Association (JAMA) by David Chinitz, PhD. JAMA. 2012; 308(8): 819-820).
Failure of international policy in LMICs to control diseases
a. To explain why MDGs couldn’t be attained in Africa despite a limited scope of action and a huge financial effort, we demonstrated that successful disease control programs require health facilities actually used by patients for their clinical care.
Unger JP, d'Alessandro U, De Paepe P, & Green A. Can malaria be controlled where basic health services are not used? Tropical Med Int Health. 2006; 11,3: 314-322.
b. We also studied the mechanisms whereby integrated disease control interventions strain patients’ access to care in those health services in which they are integrated. International programmes undermined public services while excessively focusing inputs, underfinancing them , with purchaser provider split, management property split, municipalization, and focalization of public services on disease control and on the poor.
Unger J.-P., De Paepe P., Green A. A code of best practice for disease control programmes to avoid damaging health care services in developing countriesInt J Health Planning and Management2003; 18: S27-S39.
c. We could then demonstrate that a and b together produced a catch-22 system failure because patients with various symptoms represent a pool of users that disease-specific programs require for early case-detection and follow-up
Unger J.-P., De Paepe P., Ghilbert P., Soors W., Green A. 1. Disintegrated care: the Achilles heel of international health policies. In low and middle income countries. International Journal of Integrated Care2006; 6. ISSN 1568 – 4156
For low-income populations, the mortality and suffering associated with the loss of access to individual care has been immense. The commercial delivery of health care was incompatible with Hippocratic ethics. In the absence of demand for care in public services, community participation was impossible. And health professionals were demotivated by restrictions on their clinical autonomy
Unger J.-P., De Paepe J.-P., Ghilbert P., Soors W., Green A. 2. Integrated care: a new perspective for international health policies in low- and middle-income countries. International Journal of Integrated Care 2006; 6. ISSN 1568 - 4156
Ultimately the commodification of health care, health services and health insurance leads to mortality vulnerable to health care and inefficiency in the use of taxes.
Health policy determinants
Although the model effectiveness had never been proven, the UN and bilateral cooperation agencies promoted managed competition between commercial insurers and the privatization of health services. To understand how the banking-insurance and health industries of developed countries have achieved their ends, it is on the side of the political economy of care that we must look. We thus explored the history of Ecuadorian national politics, which reveals that privatization was not always planned but also resulted from the insensitive accumulation of essentially ideological decisions.
De Paepe P, R.Echeverria, E Aguilar Santacruz, JP Unger. Ecuador's Silent Health Reform. Int J Health Services, 2012 International Journal of Health Services, Volume 42, Number 2, Pages 219-233.
USAID's history in Bolivia shows that economic issues are sometimes less important than geostrategic issues.
Herland Tejerina, Pierre De Paepe, Marie-Christine Closon, Patrick Van Dessel, Christian Darras, JP Unger. Forty years of USAID health cooperation in Bolivia. A lose–lose game? Int J Health Plann Manage 2014;29(1):90-107.
For the World Bank, on the other hand, it was a question of dismantling the public service by decentralizing it and fragmenting it with the municipalization and the devolution of health centers and hospitals.
Herland Tejerina Silva, Pierre De Paepe, Werner Soors, Oscar V. Lanza, Marie-Christine Closon, Patrick Van Dessel, and Jean-Pierre Unger. Revisiting health policy and the World Bank in Bolivia
Unfortunately, the Ecuadorian and Bolivian governments that claimed to be progressive were unable to redress the bar and pursue a policy of family medicine that would have provided access to biopsychosocial care. In question, the lack of vision of those in charge…
Herland Tejerina Silva, Werner Soors, Pierre De Paepe, Edison Aguilar Santacruz, Marie-Christine Closon, and Jean-Pierre Unger. Socialist government health policy reforms in Bolivia and Ecuador: The underrated potential of comprehensive primary health care to tackle the social determinants of health. Social Medicine, 2009, 4, 4: 226-234.
We conclude on
- the importance of supra-national organizations (World Bank, IMF, European Commission) in the strategy of insurance banks;
- the inability of the market to secure the Right to Health, to deliver professional quality care, to ensure ethical medical practice and to use taxes effectively.
- The necessarily partial nature of the privatization of health insurance (like Medicare and Medicaid in the USA).
For researchers, we have summarized our health policy investigation methodologies in the following article.
Unger, JP., Morales, I. & De Paepe, P. Objectives, methods, and results in critical health systems and policy research: evaluating the healthcare market.BMC Health Serv Res 20,1072 (2020). https://doi.org/10.1186/s12913-020-05889-w