No, it’s not April Fool’s: free health care in Zambia

The G8 summit in Gleneagles last July released $4 billion dollars for Zambia via debt relief and increased aid, and the Zambians plan to do something rather exceptional with the money: make health care free in rural areas of the country.

The background to the story runs roughly like this. In the 1980’s, many African countries were facing an economic crisis in the primary health care sector, during a period in which the World Bank and IMF sought to alleviate the economic plight of low-income countries through structural adjustment policies and conditional loan agreements – where the conditions were privatization, deregulation and lower expenditure in the ‘social’ sectors such as health care and education. It was in this general atmosphere of social improvement via liberal economic reform that the WHO and UNICEF drew up a proposal to raise the quality and accessibility of primary health care in Africa – focusing particularly infant and maternal health – and one part of the proposal involved the introduction of users fees for health services. The proposal was called the Bamako Initiative, and it was adopted in 1988 by the health ministers of the WHO Africa Region. The basic idea was that if people paid for health services, the user fees would act as revenue that could then be used to improve services and health care access for all; at the same time, the health sector could reduce its expenditures to comply with international loan agreements. It would be economically efficient and socially equitable. Everyone would be happy.

Or perhaps not: someone in the Washington or Geneva think-tanks forgot that low-income countries are low-income. Many Africans could not pay the user’s fees or could only pay if they sacrificed food, transport or school fees. The payment of user’s fees, for some, led to personal bankruptcy. Predictably, the use of primary health services plummeted in nearly every African country in which the policy was implemented. Basic indicators like vaccination coverage show that user fees discourages the poor from seeking health services, and now even WHO and UNICEF have admitted this, albeit more than 15 years after the fact.

So the Zambian government is now using debt relief and aid to eliminate user’s fees for the most vulnerable in their society. But this admirable gesture raises ethical questions too. Is this a sustainable system? What happens when the money runs dry? What about the urban poor in Zambia? What level of health care is being offered for free, anyway?