The dividing line between ordinary situations and exceptional situations is not an easy one to draw. The end of a conflict does not mean the end of the consequences of the conflict, as we have seen, and the distinction between a state of war and a state of peace may be somewhat arbitrary. For humanitarian players, however, it implies a change of position on the ground, the broad outlines of which have already been described (see p. 45, ‘Return to normal’) and a different form of dialogue with the national authorities. For these reasons, and because there may also be circumstances when it is necessary to decide to terminate a medical mission in a conflict situation, there must come a time when humanitarian organisations need to state their position on the new situation and draw the necessary consequences for the actions they are engaged in. This is a tricky decision, which relates both to the funding available and the organisations’ idea of their role, the resources they have available and also a degree of arbitrariness.
“Ordinary”, in many third-world countries where there is no armed conflict taking place, means a precarious existence for most of the population, whether they live in rural or urban environments. Until recently, the medical assistance provided by non profit-making private organisations mainly concerned the rural world. Towns and cities had been better provided for in terms of health infrastructure since colonisation, which had reproduced the models currently in use in the home country. Hospitals and dispensaries dating from these times were retained following independence, with the help of inter-governmental cooperation, most often with the former colonial powers. France thus maintained a significant network of cooperating hospitals and doctors in the so-called “reserved domain” countries, in other words the former colonies, until the 1980s, at which point budget constraints forced a rapid decrease in this type of aid.
This gradual withdrawal was nonetheless justified on other grounds than economic ones, because of the increasing number of national doctors able to take over. The limited resources allocated to health by the governments of countries in the South, however, have prevented an effective handover to local care teams. Many main hospitals were copies of buildings designed in and for industrialised countries, built and maintained for reasons that had more to do with the prestige and stability of those in power than the health needs of the population. Like other facilities offered to city-dwellers, the hospitals were part of the benefits granted to population groups whom governments needed and whose support they were seeking. The operating costs were prohibitive and funded at the expense of healthcare facilities in the rest of the country. Correcting this imbalance between town and country, if only to a limited extent, by focusing their efforts on underprivileged areas outside the towns, was therefore self-evident for private aid organisations. The smaller scale of a treatment centre offering services to all was a further reason to set them up in the peripheral areas rather than in the centre. Missionary hospitals and health centres, which were originally set up in the colonial period but then outlasted it, were also a model for international organisations to follow. Even now, this type of facility represents the largest proportion of health services offered to rural populations in Africa and accessible to the very poorest.
1. FROM ALMA ATA TO BAMAKO: THE FAILURE OF A SYSTEM
The concentration of medical resources in urban areas, principally in capital cities, has been criticised since the 1970s. Associations, experts and progressive political movements challenged, with good reason, the injustice that resulted from the colossal size and centralisation of medical facilities, which went hand-in-hand, but also the emphasis placed on treatment rather than prevention. The conference organised by the WHO in Alma Ata (Kazakhstan) in 1978 was an important moment in the history of such criticism. Its aim was “the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life”.
The means decided on to reach such an ambitious objective was “primary health care” provided by “community health workers”. The principle of free care, stated in the declarations of independence and constitutions of most of the newly independent nations, was reaffirmed. The priority was placed on health education, promoting a healthy diet and clean drinking water supplies, measures which were ranked equally with immunisation, treating common illnesses and controlling endemics. Community health workers, selected on the basis of their commitment to the community, were trained over the course of a few weeks in simple prevention techniques that were supposed to be effective in dealing with most common illnesses.
These recommendations, which naturally did not exclude health centres and hospitals (referred to as secondary and tertiary care respectively), were interpreted in various different ways by the governments concerned. Many of them, however, particularly in Africa, fell on them as a godsend, because they provided them with a legitimate strategy of under-resourcing medicine for the poor, by pushing the burden of health back onto the population. The Alma Ata principles also found widespread support outside of government, for quite different reasons. The model of the “barefoot doctor” improving everyone’s health based on his good advice in fact strengthened the preventive paradigm, according to which health is first and foremost the product of behaviour based on hygiene standards. Numerous NGOs embraced this for the same reasons. Educating mothers about how to feed their children properly, digging and covering latrines and providing basic equipment to health centres was a modest, accessible programme marked by an apparent pragmatism and endorsed by the highest authorities in relation to health. In their eyes it also had the great merit of removing health from the authority of doctors and the control of the pharmaceutical companies, since almost all illnesses, according to the Alma Ata recommendations, resulted from a lack of prevention. Once this was in place, clinical and therapeutic know-how became a mere accessory. The strategy was almost a complete failure. The criticisms of an excessively centralised healthcare system had resulted in dispersal, fragmentation and a collapse in the quality of care, of which the private healthcare market was the first and only beneficiary. A savage market in drugs developed and the number of self-proclaimed practitioners, traditional or not, grew in the face of increasing demand for care that had been met with no credible response in the eyes of the population. Over a decade later, in 1987, Ministers of Health met in Bamako at a meeting organised by the WHO and Unicef to reflect on how to revive their failing healthcare systems. The conference, known as the “Bamako Initiative” set itself the aim of raising medical standards in the primary healthcare system and providing it with essential generic drugs. In addition to the new attention paid to treatment, it also introduced financial contributions from patients, reflecting the fact that inadequate funding was seen as the principal reason for the failure. Payment for care, either on a fixed-fee or per-treatment basis, was now on the agenda, controlled by a village committee tasked with ensuring the proper use of the funds collected. Funding through “community participation” was supposed to ensure the long-term viability of a system that would offer universal access to essential drugs at an affordable price.
2. THE DILEMMA OF USER’S FEES
Improvements were seen in health centres run by competent, well-motivated nurses placed under the authority of “management committees” driven by community interest. When the conditions were right and the health authorities fulfilled their role by providing additional funding and ensuring supplies of drugs and consumables, the system worked well, but this was rarely the case and the support from NGOs was welcome. Their contribution consisted primarily of material resources – top-up pay for staff, drugs and treatment equipment. Insolvent patients were a particular focus of the humanitarian organisations and in principle they were supposed to receive free care, subject to the “management committee” defining who should benefit and limiting numbers so as not to endanger the existence of the centre.
The Bamako initiative was nonetheless viewed in different ways by the humanitarian organisations working in the health field and called on by governments to play their part in it. On the one hand, there was their commitment in principle to free care for all, which was now being challenged when it had previously been seen as self-evident. On the other, there were the problems and conflicts that arose from the availability of sums of money whose redistribution and use were a source of tension.
The humanitarian teams working in facilities where care had to be paid for were faced with some intolerable situations in human terms. Refusing to care for patients who were not able to pay, which was far from exceptional in spite of the improvement mentioned earlier in comparison with the previous system, contradicted the raison d’être of humanitarian organisations. If an NGO decided to pay for care out of its own funds to cover the costs of a particular case, it in fact encouraged exclusion, which ipso facto became a financial resource for the health centre. If it did not do so, it went against its own principles. There were cases, for example, of women who were brought into hospital to give birth being imprisoned for not being able to cover the costs of an emergency Caesarean. Surveys have shown that many people gave up seeking medical advice at all, because of a lack of money to pay for it, including in the case of serious, potentially life-threatening infections. How could humanitarian medicine, which necessarily focused on the most vulnerable, operate within a system of this kind? There was fierce debate within the NGOs concerned during the 1990s, between those who refused to participate in an unjust system and others who advocated engaging with it in order to make it more humane, although all were convinced that care should be free of charge.
Free access for all to effective health care, i.e. delivered by trained personnel with access to appropriate resources, was the only fair and acceptable policy from a humanitarian point of view. Whilst this is desirable in human terms, however, is it feasible from a practical, namely an economic, point of view? Various studies argue convincingly that it is, and this could be the outcome of the debate following a long period characterised by futile conflict. A World Bank studyK. Deininger; P. Mpuga, “Economic and welfare impact of the abolition of health user fees: evidence from Uganda”, Policy Research Working Papers, World Bank, 2003.produced in 2003 in Uganda, when the country abolished paid care, shows, for example, that the change improved access and reduced the probability of illness significantly for the poorest people. Moreover, because people were ill for less time, there was also an improvement in their economic situation, again in the poorest communities. The loss of income resulting from free care was more than compensated for by the overall benefits it brought, subject to the quality of service provision being maintained. The authors point out that the increase in the health budget and improvements to healthcare facilities, in particular ensuring regular supplies of drugs, were also important factors. This study shows that, for overall effectiveness, the public authorities need to cover and increase the level of health funding, rather than its being paid for by the population.
Undoubtedly a methodical survey needed to be carried out in such a way as to produce an unbiased result, to reach a conclusion that simply seems to be common sense. The humanitarian approach, which emphasises the need for fairness, gets along well in this case with economic pragmatism under the authority of an institution with a solid reputation for defending the former and ignoring the latter. Welcome as such a reconciliation may be, however, theory does not always equate to practice, as care still has to be paid for in most third-world countries. Humanitarian aid organisations still find themselves facing the dilemmas referred to earlier. Whilst it does not prevent them from continuing their work, it certainly adds to the difficulties of doing so.
Operating under the authority of the Ministry of Health, they largely work in two different ways, implementing so-called “vertical” or “horizontal” programmes. The former are limited to a particular area of health or even a particular infection - for example, immunisation, mother and child care, cataracts, acute malnutrition, disabilities, AIDS, vesicovaginal fistulas, etc., whilst the latter are synonymous with general health care. The problems raised by this multiplicity of programmes, which are difficult to transform into a cohesive whole, and the practical complications resulting from the coexistence of different constraints and agendas, were outlined in broad terms above. We won’t dwell on them and will now turn to the question of the legitimacy of NGOs, or in other words, their status in the political arena.
3. THE MALNOURISHED, THE DOCTOR AND THE POLITICIAN
Unlike in conflict situations, where they enjoy legal status provided for in international humanitarian law, NGOs working in “ordinary” situations are governed by national law alone. They implement fragments of public policy under the authority of the government and in practice have less room for manoeuvre than in a period of crisis. They can demand, for example, improvements in terms of food aid for people displaced by war in the context of the humanitarian standards recognised by the authorities. A similar demand in a country at peace, which may be just as well justified by the existence of nutritional problems, would not have the same status, not for legal reasons but because it is taking place in a different arena. What may be ordinary in a relief programme, for example in Darfur, may become a sensitive political issue, as was the case in Niger.
In this country, MSF saw its activities in the country suspended in 2008 by the government because it raised public concerns about child malnutrition, urging the international aid system to change its priorities and make more widespread use of products that provided appropriate nutrition for young children.For a detailed analysis of the crisis in Niger, see X. Crombé and J.-H. Jézéquel (ed.), Niger 2005, Une catastrophe si naturelle, Karthala, 2007. The tensions between NGOs and the authorities, which were already divided themselves, focused on whether there was actually a nutritional crisis at all: according to MSF, there was a large-scale crisis, which was why its feeding centres were overwhelmed, whilst according to the government, which dismissed all questions, it was being artificially inflated. MSF was welcome provided it limited itself to caring for malnourished children, as it had done for years, but it became an irritation when it made malnutrition visible to the wider society. Dozens, indeed hundreds of thousands of malnourished children in the country played out as a reminder of the country’s history and recalled the President’s own political record. “Famine! It’s enough to overthrow a regime”, read the headline in a Niamey newspaper, recalling that two governments had been ousted from power for this same reason and that the President himself had come to power in a similar context.Mamoudou Gazibo, “L’Espace politique nigérien de la crise alimentaire”, in X. Crombé et J.-H. Jézéquel, op. cit.
A nutritional mix available on the market since the late 1990s now provides a way of caring effectively for children suffering from severe malnutrition in just a few days, whereas previously they required hospitalisation and intensive care. According to nutrition specialists, its use as a food supplement, in various forms depending on the degree of malnutrition, would considerably reduce infant mortality.For an analysis of the limitations of this development, see Martin Enserink, “The Peanut Butter Debate”, Science 3 October 2008: Vol. 322. no. 5898, pp. 36 – 38.For doctors, the paste, marketed under the name of Plumpy Nut, represents an advance comparable to the development of antiretrovirals in the treatment of AIDS. Over 90% of children renourished with this easy-to-use product have been cured, which justified expanding its use. But what was medically acceptable for AIDS proved to be politically very sensitive for malnutrition, to the point of causing the NGO that exposed the scandal to be expelled. In the first case, the medical and humanitarian angles were complementary from a political point of view, whilst they ran counter to it in the second.
It is no doubt not purely coincidental that an NGO from the old colonial homeland was taken to task by the authorities, even though the opposition and part of Niger’s press took hold of the issue and turned it back on the president on the basis of his own political responsibility. “By denying the existence of the famine,” wrote an author from Niger, “Tandja has made himself liable to the High Court of Justice”.
Salifouize Ibrahim, in “La Roue de l’histoire”, no. 261, 16 August 2005, cited by Mamoudou Gazibo, op. cit.
For others, many of them supporters of the president, MSF was reverting to colonialism by trying to impose its views on a sovereign government. They accused humanitarian organisations and the international media of exaggerating the crisis for publicity purposes, in order to paint a humiliating picture of the country.
It is fair to say that in calling on the authorities to make child malnutrition a health priority, MSF was laying itself open to this kind of criticism, which it would be simplistic to regard as purely opportunistic. An African NGO taking the same position would not have been subjected to the same attacks, the nationalist roots of which are not, however, specific to Niger. The same diffuse hostility, which has grown over recent years, can be seen in other African countries where Western NGOs are present in large numbers. It is easy to understand the irritation they cause, though that does not justify the aggressive behaviour to which they are subjected. An example is the unanimous anger in Africa that followed the “Zoe’s Ark” affair. What some people view as protecting human life is simply colonial paternalism in the eyes of others.
The controversy was not in vain, however, as measures were taken by the authorities in Niger to improve infant protection. Malnutrition is now also included in the country’s national statistics when it was ignored previously. Now it not only shows up in the figures but is acknowledged as a public health issue.
4. RICH COUNTRIES
The value of humanitarian doctors will have been to make a serious, overlooked problem visible by making the situation public and implementing a solution at the same time. The appearance of the phenomenon of “extreme poverty”, described in the 1980s by the founder of ATD Quart-Monde, prompted a similar reaction in France. Médecins du Monde, then MSF and others set up medical and welfare centres in a growing number of towns, providing care and helping their patients to reintegrate into the public health system where possible. Buoyed up by a sense of grassroots legitimacy, both were active in highlighting in the press the shortcomings of a care system that rejected patients who had reached the end of the welfare entitlements. MSF and MDM believed, not without good reason, that the adoption of the law on Universal Health Insurance (CMU) in 1999 owed a great deal to the campaign they had fought, which made it possible to shut down a number of their medical centres. They continue to operate in France, targeting their activities at marginalised groups such as asylum seekers who have been refused entry, and the homeless.
In the United States, where a growing number of patients have no access to care, humanitarian dispensaries saw the number of consultations increase rapidly in 2008. Although it is a legitimate question to ask, it is difficult to imagine European medical NGOs being deployed there. In any event, religious organisations have expanded their activities in this area in recent years, with the support of the Bush administration. Is this a path that European governments might follow, in light of the economic crisis? Could something that is acceptable in the United States be possible in Europe? The temptation to delegate some proportion of society’s ills to NGOs, medical or not, was evident in France in the 1980s and 1990s, and it was as an explicit rejection of this role that MDM and MSF launched their campaigns. A similar scenario could occur again, placing humanitarian organisations in the position of rebellious auxiliaries of a failing public health system. No doubt the NGOs would mobilise again, though the result may not be a foregone conclusion.