Health Not for All in the Greater Mekong Sub-region

BANGKOK, Jan 3 - As 2008 came to an end, so did the World Health Organization's commemoration of the 30th anniversary of the Declaration of Alma-Ata. Launched in late 1978 at the International Conference on Primary Health Care, the Declaration affirmed health as a fundamental human right and boldly proclaimed the goal of attaining health for all peoples of the world. It stressed the socio-cultural and economic determinants of health. In the spirit of social justice, it also declared that the inequities in health between developed and developing countries were politically unacceptable and needed to be collectively addressed through structural changes.

Today, these 30-year-old values still resonate across the world, not least in the Greater Mekong Sub-region (GMS) where unequal socio-economic development is associated with uneven levels of health and well-being within the same geo-political area.

HEALTH/WEALTH DIVIDES

In the GMS, the more economically advanced countries and groups have higher levels of human development, including in education and social welfare, than poorer countries and groups. Citizens of the three wealthier countries of China, Thailand and Vietnam have higher education levels, are more accustomed to information and communication technologies, and have greater access to safe drinking water and sanitation in comparison to the rest of the GMS population.

Differentials in quality of life are intertwined with differentials in health, with the population of Thailand, China and Vietnam generally living longer and healthier lives than their neighbours. Life expectancy at birth in these three more privileged countries is on average 10 years higher than in the disadvantaged countries of Burma, Cambodia and Laos.

Correspondingly, infant and maternal mortality rates -- two of the most important indicators of health and well-being -- are much lower in the wealthier countries. At the two extremes, Cambodia’s infant mortality rates (IMR) are about four times more than Vietnam’s, the country with the lowest IMR in the region (93 and 17 infant deaths per 1,000 live births respectively in 2004). What is more, Cambodia's infant and under-five mortality rates have been increasing in the last decade, while those of the other GMS countries have been declining or have remained stagnant.

A similar divide characterises the occurrence of maternal mortality in the region. In Burma, Cambodia and Laos, maternal mortality ratios are strikingly high, ranging from 300 to 600 deaths per 100,000 live births in 2004 to 2005. In Thailand, China and Vietnam, the rate was around or below 100 deaths per 100,000 live births during the same period.

In the midst of the region's epidemiological transition toward so-called "diseases of affluence", poorer GMS countries continue to do battle with "diseases of poverty". Whereas obesity and diabetes are on the rise in the wealthier China, Thailand and Vietnam, in disadvantaged Laos under-nutrition remains widespread, with almost half of children stunting and with low haemoglobin levels.

GEO-SOCIAL VULNERABILITIES

Inter-country divides are replicated within countries, with economic determinants again playing a critical role in shaping human development. Irrespective of national incomes, GMS countries have health levels that are consistently lower in rural areas, a reflection of the lesser degree of infrastructural development, lower literacy levels, and higher levels of poverty compared to urban areas. Urban dwellers are better linked to services and markets and have greater access to water and sanitation, energy, transport, and information, all conditions essential to health.

The disparities among different localities and social groups within countries are striking. In Thailand, the two poorest regions of the North and the North-east rank lowest in terms of human development, including education and health. In China, the economically disadvantaged provinces of Yunnan and Guangxi have among the worst health indicators in the country and extremely high rates of infant and maternity mortality. As an illustration, in 2002 life expectancy at birth in Yunnan was about 10 years lower than the average of 71 years for China as a whole.

Against the backdrop of variations across different areas, social groups and households show different degrees of poor health across a number of socio-economic and demographic characteristics, including class, occupation, gender, and age. Particularly vulnerable are migrants, refugees and, especially, ethnic minorities, whose marginalisation is reflected in their much lower health status and higher burden of communicable diseases when compared to the majority population. Among upland ethnic communities, malaria is one of the main causes of death, together with diarrhoea, dengue fever and tuberculosis. In Thailand, IMR among ethnic communities is 1.7 times higher than the national average, and in the Central Highlands of Vietnam, protein-energy malnutrition remains rife among ethnic minority children.

INEQUITABLE HEALTH SYSTEMS

Resources are still not distributed according to where the greatest health needs are.

At the regional level, richer Thailand allocates the greater GDP proportion to health, while poorer countries allocate smaller proportions of their more limited budgets to health, in spite of the greater health needs of their populations. At the country level, budgets, services and personnel services remain biased toward urban areas and public health efforts fail to sufficiently reach the most vulnerable groups. Because of the curative bias in health policies and the larger concentration of more expensive hospital facilities in the urban areas, national health budgets in the GMS are disproportionately distributed to the wealthier urban provinces. Ironically, per capita government expenditure in more disadvantaged, and less "healthy" provinces is lower than that in more advantaged provinces.

In Thailand, hospitals and health centres are gathered in the economically advanced capital Bangkok and its surroundings, whereas in the North and North-east, fewer facilities serve larger populations with less financial and human resources. High-tech equipment, such as CT scanning and mammogram machines, are scarce in the "periphery" and so too are medical professionals and specialised nursing personnel. The total number of facilities, especially private ones, is growing rapidly, but this is because of the booming tourism medical industry devoted to foreign and high-class Thai patients. Thus, these are concentrated in the main tourist locations and not affordable for the majority of the population.

In other GMS countries, services are similarly more accessible and of better quality in the urban areas, with rural dwellers having fewer opportunities to be treated by a doctor than urban residents. In Laos, access to health facilities for rural residents takes 108 minutes, but only 19 minutes for urban ones. A quarter of the poor lives in villages with medical personnel, vis-à-vis half of the non-poor persons.

Ethnic minorities lack access to many services taken for granted by the majority population, and when they do receive health care, the quality is below the national average. Services also fail migrants, who are often excluded from care provision because they lack citizenship or residency entitlements, or because they cannot afford the costs. More generally, the poor in the GMS have to devote a relatively higher proportion of household incomes to health than the rich. As the increasing privatisation of the health sector and drug prescription and use of more sophisticated technologies drive up the prices of health services, the poor resort to self-medication or traditional healers, leave diseases untreated, or get into debt to meet mounting out-of-pocket expenses. Data from the Cambodia Demographic and Health Survey show that in poorest provinces, 25 percent of patients abstain from seeking care, while in wealthier provinces five percent or less do so.

Health appears not only to be affected by poverty, but also to cause it. A recent study commissioned by the World Bank reports that health costs in Cambodia account for 60 percent of landlessness cases and for 13 percent of loans, with health-related income losses increasing the estimated poverty headcount index from 34.7 to 37 percent.

A WISH FOR 2009

To address these persistent disparities, appropriate policy and intervention responses need to be formulated. As a precondition to fostering an enabling environment, public discussion ought to start on the distribution of health outcomes, access to services, and costs of care, taking into account the unbalanced development that is at the root of health inequities in the GMS. Principles of equity and universality appear to be as relevant now as they were at the time of the Alma Ata Declaration, if indeed health and health care are to become a "basic right" and an "entitlement" for all the citizens of the GMS rather than an exclusive benefit for privileged ones. Still, they have so far barely been articulated in health programmes and policies.

Let the 30-year commemoration of the Declaration end in 2008, and let’s see the actualisation of its core principles start in 2009!

(This article uses information gathered by the author for the International Development Research Center (IDRC) on Health Governance and Equity in the Greater Mekong Sub-Region.)

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Any views or opinions expressed are solely those of the author and do not necessarily represent those of the organisations she is or has been associated with.

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*Rosalia Sciortino, better known as Lia, is a cultural anthropologist and development sociologist by training, who is currently working in Thailand as Associate Professor at the Institute for Population and Social Research, Mahidol University, and Visiting Professor at the Masters of Arts in International Development Studies at Chulalongkorn University. She also consults with the World Bank, IDRC and other development agencies. Before that, she was Regional Director of the Rockefeller Foundation Office for Southeast Asia in Bangkok, overseeing grant-making activities in the Greater Mekong Sub-region. She also worked with the Ford Foundation in Indonesia and the Philippines, and has published widely on development issues. A native of Italy, she has lived in Asia for nearly two decades.