Here we are at the Costa Rica Marriott Hotel, where – happily – the World Bank is picking up the hefty tab. This appears to be a top-of-the-line Marriott, featuring faux hacienda architecture and hot and cold running maids. But instead of a coffee plantation outside, we’ve got a championship golf course and an Olympic water-sports center.
After we’ve stowed our laptops and sent faxes to our offices to let them know where we are now, we gather downstairs in the Juan Vasquez de Coronado Grand Salon to open the discussion of this week’s stimulating topic: “The Challenge of Health Reform: Reaching the Poor.” The World Bank and the Inter-American Development Bank, together with their stable of hired experts, are debating the issues involved in providing health care to people who can’t pay much – or worse, can’t pay anything. This is going to be a challenge all right, especially if the bankers intend to make money doing it, which they certainly do.
As we all know, the international banks have long been deeply concerned about the health status of the Latin American poor. This year, they are alarmed to note that, in spite of the help that the Banks have provided for the last five decades, poor people continue to have a lot more diseases and die much younger than rich people. Curiously, even after all the attention they have received from the banks in recent years, poor people in much of Latin America have a better chance now of dying right off the bat – at age zero – than they did five years ago.
The banks are baffled by the persistence of poverty and misery, but they are determined to use their best brains to think up innovative new ways to get those vaccinations and vitamins out there. The methods will have to be imaginative, because the banks don’t want to spend a lot of money unless it will “contribute to the development of the private sector.” And the private sector does not want to feed and vaccinate people who can’t pay. The private sector wants to make money – that’s why it’s private. And since banks are – after all – banks, and not charitable institutions, they too want to make money, which is why they get along so well with the private sector, and so poorly with the public.
The public health and social security ministries typically are supposed to look after the whole population of their various countries, but up until now, this has been difficult. Money has been scarce, particularly in Central America, where for so many years, public funds were spent to pay for those huge armies. After the governments got through shooting people down, there usually wasn’t much money left to fix them back up. And so it was good news when we heard that the World Bank and the I.D.B. planned to lend money to Central American governments in order to improve health care for the poor. But as in everything else the Banks do, you want to be sure that you read the fine print.
As we discovered by reading the “Challenge of Health Reform” materials closely, the World Bank and the I.D.B. are going to reach the poor by lending money to governments, who will in turn pay it to companies, who will then make sure that poor people get their check-ups and eat their gruel. There is only one problem with this scheme: if you are a private company instead of the public health service, and you are paid to provide care, the skimpier your treatments, the more money you make. And you don’t have to be especially imaginative to figure this out.
Let’s take a look at the I.D.B.’s initial effort in Guatemala. After the civil war came to an end in 1996, the government’s policy on the poor indigenous communities out there in the hinterlands changed abruptly. Instead of killing Indians, it wanted to borrow money to take care of them. Always willing to assist in humanitarian efforts like this one, the I.D.B. agreed to sponsor a project that allowed the government to contract non-governmental organizations to do the job. Under this pilot project, virtually any N.G.O. could qualify for a contract, there was neither monitoring nor evaluation, and contracts have been automatically renewed each year since. Best of all – the N.G.O.s were paid on a per capita basis. That means that if you make yourself into an N.G.O. and propose to deliver the subsistence health care package to 50,000 people, you’re paid 50,000 times the dollar amount of the package, plus your administrative costs. If you propose to cover 100,000 people, you’re paid double that. And no one has any way of knowing whether you gave the babies the check-ups or you bought yourself a condo in the Caymans.
Officials at the ministry sought proposals from N.G.O.s by advertising in newspapers and on the radio, and by inviting their special friends to participate. The I.D.B. was gratified at the enthusiastic response the contract offer received from the Guatemalan N.G.O. community. The Bank meant to start small, by initially contracting only eight N.G.O.s, but N.G.O. interest in the project was just overwhelming. The government seemed anxious to move faster, too. In the end, seventy-four N.G.O.s and private companies joined up, many with multiple contracts.
Predictably, the Bank reports that “according to anecdotal results” (derived from interviewing the contracted N.G.O.s), immunizations increased five-fold in 1999. A spectacular achievement. Notice that no Indians were contacted, however. We suspect that what these anecdotes really suggest is that the government paid for a five-fold increase in immunizations – a spectacular amount of money. Nonetheless, if smallpox breaks out in any of the project’s target areas, you should not be too surprised. And you will probably want to scoop up your babies and get the hell out of there. You will undoubtedly notice that the putative immunizers are preparing to bug out, too – if they ever arrived in the first place.
The I.D.B. is now investigating ways in which it can make this project expandable and sustainable. It is a great success: the Bank is happy, the government is happy, and the N.G.O.s are happy. Unfortunately, no one has thought to ask the Indians if they are happy, but that’s because they’re not conveniently located and they don’t speak Spanish very well. So, tough. And of course, the Guatemalan government is now further in debt to the I.D.B., for money granted to disappearing – and possibly mythical – N.G.O.’s.
In neighboring Honduras, the World Bank has dreamed up another promising initiative. This one is not quite so profitable as the Indians’ health care gravy-train in Guatemala, but it is creative in that it costs almost nothing and it looks generous. Here at the Health Care Reform conference, the Bank presents the project as “Integrated Child Care: Improving Health and Nutrition at the Community Level.”
This project is a marvel of semantic confusion and cheapness. Integrated child care amounts to providing one week of training to volunteer women from the lucky community and giving them manuals, tracking charts, and a scale for weighing babies. The volunteers periodically weigh the village babies and figure out how fast they are getting bigger. The project does not provide the volunteers with any food or medicine for unfortunate babies who fail to fatten. This does not seem very integrated, but the sponsors of the project explain that it involves a “change of paradigm” for malnutrition treatment. This particular paradigm shift consists of providing education about nutrition to the mothers of the hungry babies, rather than food. The Bank’s experts on malnutrition changed the paradigm because they noticed that the ignorant mothers gave their babies watery soup to eat, which was not very nourishing, rather than feeding them yummy thick soups with beans and potatoes. The Bank’s experts on nutrition apparently lack expertise on vegetable prices, or they would know that water is cheaper than beans and potatoes – at least temporarily, until the Banks come up with an integrated water-services reform project.
It may be true that rural mothers lack nutrition information and could benefit from having some. But after they get the information, it would help if they also had some food. Unfortunately for them, food costs more money than weight charts, and so they’re not getting any.
Notice, too, that the project personnel are volunteers. Women volunteers. The Bank believes that – in the words of one of its experts – “Rural women are a tremendous investment. They give and give and give.” What a deal. Here are the impoverished rural women in the outback of Honduras. They are raising the children, preparing the miserable soup, hunting for firewood, hauling water, tending the garden, selling the tiny surplus in the market on Wednesdays and Saturdays. At twenty-five, they look like they’re fifty, and now – in their spare time – they can be volunteer health monitors.
The director of the Guatemala Health Care Company Enrichment Project pipes up to point out that in her country, rural women love these kinds of service opportunities, if they get a badge with their name on it that identifies them as official health monitoras. And, the Bank experts argue, the Honduran women received intrinsic rewards for their trouble as well as more tangible ones: a letter from the minister of health one month addressed directly to them, a special party in their honor, and a little badge to wear. We point out to the Bank experts that they themselves seem to prefer to work for money rather than parties and badges. This makes us very unpopular for the rest of the long afternoon.
During the presentation and the discussion of these projects, all of us are constantly filmed by Bank P.R. people, probably to be presented somewhere else as health care experts earnestly seeking solutions to stubbornly high infant mortality rates in Central America. Sure enough, when we finish talking, we are treated to a video about the Honduras project, which shows the smiling monitoras weighing big-eyed babies in hanging scales, like turkeys.
We have learned a few things at this conference. First, never, never, ever trust anything the World Bank or the I.D.B. calls a “reform.” Second, a “change of paradigm” means doing the same thing more cheaply and having it look better, and third: the Banks are interested in private sector money-making, and not much more. If this is to be achieved by gutting the public health service, by cobbling together alternative health care systems that don’t really exist, by inventing anecdotal vaccination statistics, and making perky videos about how things are much better now, then fine.
It’s as easy as taking a bottle from a baby.
Gabriela Bocagrande is the Observer‘s monitora of imperial chicanery.