In Iraq, displacement, lack of income, insufficient diet, poor sanitation and lack of safe water sources, and the trauma of war have been taking its toll on the health of the internally displaced. Provision of much-needed health service is being hampered by security concerns.

“Health care in Iraq deteriorated greatly over the last decades as result of the repeated wars, sanctions and the generalised violence and conflict since 2003. This deterioration in health services also resulted from the exodus of qualified professionals, a severe shortage of medication and equipment, and damage to medical facilities.” (IDP Working Group, 27 June 2008)

What are the responses of the international community to address the health situation and problems confronting Afghanistan and Iraq?

In Afghanistan, the UN World Food programme is calling for more food aid to the war-torn country. In Iraq, on the other hand, the US claims that it has poured assistance for the rehabilitation of hospitals and health centers.

How would these responses impact on the health and well-being of the people of Afghanistan and Iraq? Let us now take Somalia as an example.

In Somalia, a country torn apart by a civil war since the US-backed dictator Siad Barre was toppled in1991, recurrent droughts and the war have caused widespread famine. The response of the international community has been to flood the country with food and other “development” assistance.

Historically, aid agencies have been in the country since the early 1980s. The USAID funded agricultural training projects encouraging the nomadic Somali people to practice semi-permanent agriculture. This destroyed the traditional coping strategy of Somalis during droughts. Consequently, it made them dependent on food aid. And since aid agencies have been flooding Somalia with food supplies from Western countries, food aid became the most traded good in the market. Eventually, food aid destroyed the agricultural economy in Somalia because the traded food is much cheaper than the products being produced by farmers. So the aid which was supposed to solve the hunger problem in the country would, ironically, become the source of famine in the future once the flow of food from Western countries is stopped.

So if food and other “development’ assistance would not, in the long term, help a country being ravaged by war and hunger confront its health and other basic needs, especially if it is being regarded not as a temporary, stop-gap measure but as a policy response, how about the rehabilitation of hospitals and health centers. Surely, the people would benefit from the increase in capacities of hospitals and health centers.

A study with the title “Public spending on health care in Africa: do the poor benefit?” by F. Castro-Leal,J. Dayton, L. Demery, and K. Mehra looked into health spending of the governments of select African countries: Guinea, Madagascar, CoÃte d’Ivoire, Ghana, Tanzania , and South Africa. The study aimed to determine to what extent government health spending has been effective in reaching the poor. All the African countries, which were included in the study, have a three-tiered public health system: there were clinics and dispensaries at the first level, district level hospitals at the secondary level, and referral and specialty hospitals at the tertiary level. Government health spending was biggest at the tertiary level.

What were the results?

The study revealed that since government health spending was focused on curative health care, it benefited the more well-off rather than the poor. This is because the poor rarely access curative health care services unless in dire emergencies. The study attributed this to the attitude of the poor to regard illnesses as a normal feature of life and to a lack in information. It concluded that to target the poor, government health spending should focus more on primary health care and less in hospitals.

This is also true in the Philippines, the poor are wary of going to hospitals because they lack the money to spend on tests and medicines, which are not being provided for free even in government hospitals.

Why?

The globalization policies of deregulation, liberalization and privatization have resulted in the decreasing government budget and spending in health. This forced government hospitals, with substantially slashed budgets, to undertake cost recovery schemes by charging for services that used to be subsidized, and reduce the allocations for indigent patients. This also made the deficiencies in supplies, medicines and personnel of health centers even worse.

To address this, health NGOs and advocacy groups have been campaigning for an increase in government budget and spending for health while training and supporting communities in setting up community health programs with focus on primary health care. Health NGOs also support communities in establishing a health referral network for their tertiary health care needs.

Ironically, the Philippine government and its armed forces do not view this favorably. As part of its counterinsurgency program, the government and its military have been targeting health workers servicing far flung communities and accusing them of being enemies of the state who are influencing the people to fight the government. Health workers servicing poor communities have suffered the brunt of the enemy-centric and population-centric approaches of the AFP: being targeted as enemies of the state without regard to the fact that they are unarmed and have merely been providing much-needed health services and being treated as competitors in influencing the people. This has been the experience of the Morong 43. We have also been receiving reports from Chestcore, a health service NGO servicing communities in the Cordillera region, that its staff have been receiving death threats. There were also medical missions that have been blocked by the military.

What should committed health workers do then?

To be able to address the health problems of the people and enable them to improve their quality of lives, should health workers confine themselves to hospitals in the hope that the poor would eventually access their health care services? How could health workers confront the problem of diminishing health budgets that result in understaffing, machines that always break down, insufficient supplies and medicines? How could health workers enable peoples and communities to access and enjoy their right to health?

In situations of armed conflict, how could health workers confront attacks on the people’s right to health, as well as attacks on their safety and well-being? How should health workers address the additional problems of lack of food, displacement and poor living conditions, and trauma injuries, which are prevalent in situations of armed conflict?

Should health workers confine themselves to providing curative and emergency health services, while projecting themselves as neutral providers of humanitarian assistance or perform multiple roles as health service providers, advocates for the people’s right to health as a basic human right, and activists who organize, mobilize, and enable communities to assert their right to health while taking care of their primary health care needs?

This article is a talk given by the author during the 8th Finnish-Philippine U.P Global Health Course, which is an undertaking of the University of the Philippines College of Medicine and the University of Tampere, last August 9, 2011.

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