Abstract
Background
The key questions
Do people really have choices?
A critical look at GOBI and the Child Survival Revolution
The efficacy of GOBI
The implementation of GOBI
References
Family Practice, Vol.7, No.4, 1990. and
J. of Trop. Pediatrics, Vol.35, Aug. 1989.
CLAUDIO SCHUFTAN
schuftan@gmail.com
Abstract
The purpose of this paper is to critically examine what has come to be known as the Child Survival Revolution, a programme launched by UNICEF to promote growth monitoring, oral rehydration therapy (ORT), breast-feeding and immunizations in the Third World. These four health interventions have collectively come to be known as GOBI or GOBI-FF if one adds the provision of food and family planning services.
Two (not necessary original) hypotheses will be explored here: firstly, the child survival revolution cannot work in isolation. It must be tied to other, more fundamental changes in political and economic power structures: secondly, the success of these interventions is inextricably tied to their acceptance and implementation at the grassroots level (a bottom-up versus a top-down approach).
Background
The idea of a Child Survival Revolution can be traced to the 1978 Conference on Primary Health Care held in Alma-Ata, USSR. Out of that conference, attended by government representatives, health providers and development workers from around the world, came a revolutionary document, The Declaration of Alma-Ata, which asserts that health is a fundamental human right and that responsibility for assuring this human right through the provision of primary health care lies not only with people themselves, but with the governments which represent them. The Declaration notes that attaining the highest possible level of health ‘is a world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.1
Shortly after the conference at Alma-Ata, however, doubt began to be expressed about whether there were the resources or commitment to achieve the Declaration’s goals. In 1979 Walsh and Warren proposed a program of ‘selective’ primary health care which would focus on a smaller, more attainable set of objectives.2 From this was born, much later, the idea of the UNICEF-sponsored Child Survival Revolution which would focus on tour basic health interventions designed to save the lives of millions of children each year.3
The key questions
Many well-founded doubts have developed about the Child Survival Revolution as a second best approach to primary health care: Is it a revolution failing or going sour?; a non-revolution to start with?; an exercise in Nairobi. Kenya. futility?; a technological fix?; a stop-gap measure?: a finger in the dike?; another gimmick just buying us some more time? Are we just showing up for a race that we are not going to win?4
All of these questions are specifically brought up here to sound a warning and make us realize about why we are not going to achieve ‘Health For All By The Year 2000’, through any second-best approach.
Evidence of rising levels of malnutrition and stagnant infant and child mortality rates come at a time when real government health expenditures per capita have actually declined in many countries. How can those living under the constraints of dire poverty take primary responsibility for individual and family health through GOBI alone? How can they dream of making positive choices that would lead them to healthier lifestyles?
Do people really have choices?
Choices like lighter workloads and more food during pregnancy, long-term commitment to breast-feeding, adequately feeding a child during periods of illness, using ORT, weighing the child periodically, vaccinating him/her and choices about child spacing are all intimately linked to the state of poverty of most beneficiaries of GOBI-FF. Some additional empowerment is needed for meaningful choices to become realistic options.
A critical look at GOBI and the Child Survival Revolution
What UNICEF now describes as a revolution in child survival – is really no more than a watered down version of a few of Alma-Ata’s essential elements of applying a technological solution to outstanding health problems. At the same time. those elements fail to address the political, social and economic roots of the very same health problems.
UNICEF has thus depoliticized the Child Survival Revolution’s potential to bring about real, lasting changes in the health of poor children in what remains of this century.
Along the same lines, the former administrator of USAID tells us the investments in new and improved health technologies are going to revolutionize health care in the Third-World and ‘we plan to accelerate the pace of research in this area selecting the most promising technological advances for implementation – those that promise the greatest pay-offs in improving health and health conditions. These programmes will provide a lasting contribution to the overall health and economic progress in even the poorest of countries.’5
Conversely, what Alma-Ata painstakingly established was primary health care as a concept encompassing a technical package, plus a call for democratization and decentralization of the health sector’s infrastructure and suprastructure that is to lead to increased coverage of services delivered equitably and at low cost through a network of community health workers. The totality of these elements was meant to establish a whole new philosophy of participation leading to a greater control by the people over their own health. Of course, this can only be achieved by reshuffling all priorities in health through deliberate planning guided by the principles of this new philosophy.
The Revolution has been hailed as having a new potential for people to care for their own health needs: being a social movement that permeates our lives:6 being a breakthrough of an altogether different order. But no evidence for these claims is ever given. These statements are thus filled with rhetoric. The director of UNICEF has even said: ‘It is time to promulgate a new law of emancipation to liberate those in the slavery of infant and child death… this is a quantum leap forward.’7
The truth is that the last three decades may have seen the development of numerous health technologies, but not of enough compassion and, above all, enough creative anger to offer real lasting solutions that can more permanently and effectively protect poor children from the preventable diseases of childhood and ultimately from a close chance of death.
The efficacy of GOBI
UNICEF estimates that for every US $100 spent from the Child Survival Fund a child’s life is saved. But this simple accountable indicator, focusing on infant or child mortality rates alone, is actually deceiving. It fails to address changes in the wider set of quality of life indicators for those children brought about by the Fund’s disbursements, e.g.. Data on malnutrition rates, on the amelioration of the economic impact (not only incidence) of infectious discuses overall, on the status of sanitation, or on a host of other non-health indicators. It says nothing about whether the causes of infant and child death have changed and what has happened to death rates for older age groups, i.e.. are children just dying at an older age or are mortality rates really lower across the board?
Because it is expected that the Child Survival Revolution will change demographic patterns in infant and child mortality, we still need to explore why children are not surviving; what are they now dying from and when?8 For instance the death rate due to diarrhoea is 100-300 times greater in the third world than in the USA This needs to be compared with the income gap of at least 40 times between the poorest groups in both worlds. Diarrhoea is only the last trigger that seals mortality; its complex causes are related to poverty. Averting deaths from dehydration in diarrheal diseases is thus just a stop-rap measure.
GOBI and the Child Survival Revolution are not ‘the engines to drive primary health care to the far reaches in every country’, as USAID’s administrator wanted us to believe.9 GOBI and the Child Survival Revolution cannot by themselves translate a narrowly defined political commitment to children’s health and well-being into lasting, effective and dramatic results. even by using dramatic, proven, life-saving, low-cost interventions.
The social factors that restrain families from using new GOBI technology may well be the same factors that predispose them to higher risks of infant and child mortality. If so, the cost effectiveness of the GOBI approach will end up being far lower than anticipated.10
The implementation of GOBI
UNICEF itself and. even more importantly, the other agencies that have since adopted GOBI, have had some experience with it by now. The big donors, like AID, have taken a much more top-down approach in the application of GOBI while certain non-governmental organizations and grassroots groups may be using more bottom-up, people-centred approaches (e.g. the former seem to emphasize the prepackaged ORT packets and the use of social marketing techniques, while the latter rely on the more empowering home-made solutions and community education through participatory campaigns).
Big donors traditionally implement changes passing through existing government institutions. But these institutions are structured to turn out only certain decisions, even if those who run them are progressive thinkers. It follows that it is those institutions (and the limits of their decision-making) that actually need to be changed. We know that aid goes through bureaucracies and that these bureaucracies respond to the demands of the power structure, not the demands of the people.11
Unfortunately, most international health aid still considers health primarily a commodity to be delivered by experts and only passively received by the general population. Moreover, aid tends to pass on the responsibility for poverty, hunger and ill-health to the poor, the hungry and the sick.12 Further critical evaluation of the impact of international health aid on people’s health in The Third World is sorely needed since imported health care delivery systems based on the ‘health as a commodity’ philosophy have traditionally added more to the problem than to its solution. I seriously doubt that GOBI is an exception to this.
Fashionable theories from the Metropolis can sometimes precipitate the death of unsuspecting aid recipients in the periphery. In situations of dependency, projects are often conceived by large Western consultancies: not always badly, but using an inappropriate Western model. Many of these projects consume sums that are vast in Western terms, but gigantic for the Third World. To what avail? One cannot just thrown money at a problem and hope that it will go away.
Putting it another way, Mahler, ex-director of WHO, said: ‘There is always the danger that the self-cleansing, self-righteousness of giving to the unfortunate poor will blind the givers to the need for more fundamental, long-term solutions.’13 Non-governmental organizations are often left to pick up the pieces of official schemes gone sour, sometimes refocusing programmes in the right direction, with a heavier grassroots participation component, but unfortunately, at times, only becoming the execution arm of those ill-conceived big donor schemes.
The hard questions we are left to answer, then, are: (1) Are present health interventions in the Third World following a path of development which suits the people’s needs rather than foreign interests?; and (2) to what extent are health professionals involved in those programmes prepared to look with fresh eyes at their own practices and modify these so as to meet the real needs of these (mostly rural, but also increasingly urban) poor people?
A fresh look is called for to investigate the role of transnational corporations, pharmaceutical houses and overall private enterprises in the Child Survival Revolution (e.g., as producers of ORT packets, as mass marketing specialists, as drug and vaccine suppliers and as health equipment producers). The same need exists for an inquiry into what possibly maybe. for some, a hidden agenda of decreasing the fertility rate of the poor, an aim commensurate with population control.
Communication technologies used in GOBI could empower the people, but this will depend on its content. If the media would be used for conscientization (consciousness raising) and for popular mobilization purposes in addition to making people consumers of services or goods, it could become a tool of empowerment; at present, it certainly is not.14
The same communication technologies are also being used, mostly in the countries of the North, to sell GOBI to potential donors and to the public at large as this ‘revolutionary hew approach’. All this is done with a great flare emphasizing image rather than substance.
There is some controversy about the marginalization of women in the Child Survival Revolution: debate is taking place even within UNICEF.
Women provide more health care than all the world’s health care services put together. It is the mother who must recognize and treat common diseases or decide to seek outside help. But educating mothers just to do this better is not enough. Women’s (and their families’) lives have to be improved directly first. How does GOBI achieve this?… Hardly at all.
The Child Survival Revolution – and the notion of primary health care in general – will not get far in the long run unless other, more fundamental, changes in the distribution of resources and in national priorities take place. Countries that have been successful in implementing various aspects of GOBI, such as Jamaica and Indonesia, are clearly different to other countries which have made a more global commitment to improving the lives and health of their poor (e.g., Nicaragua). Finding out exactly why and in what ways this is true is still an open research avenue.12
Under what circumstances and in what context(s) then could the Child Survival Revolution work? What is needed to really increase children’s well-being?
The major challenge lies not in the four components of GOBI, but elsewhere. To improve children’s’ quality of life overall, a fully integrated program is needed; one which explicitly addresses and leads to structural changes through genuine empowerment of the beneficiaries. People must be empowered to make their own choices and thus to serve their own health needs by mobilizing their own resources.15
For the rural and urban poor there can only be one meaning of development and better health: an appropriate return for their labour and the right to land ownership, to jobs and to their basic needs being met. These should not be provided as privileges granted by the rich, but as their rightful dues as nationals and as working people.16
Instead of performing lengthy feasibility studies, writing endless reports and holding meetings to evaluate past reports from past meetings, we had better get down to the business of finding concrete ways for rural and urban poor people to make money and improve their living conditions.17 Ideas alone wilt not magically convince and change key actors and decision makers. We need to start and become involved in processes of social mobilization, even at the risk of facing repressive beaurocracies.14
Unfortunately, we are trained to ignore the question of who the health services serve. We assume that this question is superfluous as the answer is supposed to be obvious; we are made to believe that services are for all people, In a society divided into classes there cannot be services that are equal for all people. The needs of peasants, fishermen and factory workers cannot be satisfied by a system that primarily was designed to serve the needs of the rich. In that sense, health is not neutral, we have to make services relevant to those who need them most. Together with informing beneficiaries about their health we are to give them information about their poverty and whether this is inevitable?16
We cannot depoliticize health in the search for a lasting solution. To do so is failing, over and over again, into the trap of looking at health as a technical challenge at a time when we continue to experience deteriorating health statistics in the Third World. Ducking the issue with statements like: ‘technology alone is an empty answer to development unless it’s given with compassion and love’18 is empty nonsense. Compassion and love are just not the attitudes with which one can successfully change a harsh reality. Charity is simply not good enough.
Social support systems and determined (political) human actions are the key elements for success in applying even the most basic, time-honoured health technologies.19
Finally, recent calls for adjustments with a human face made by several high-ranking UNICEF officials20 when underdeveloped countries face the vagaries of IMF pressures, the debt crisis, balance of payments deficits, inflation and unemployment – are unfortunately naive. They call on governments to spare (externally) imposed budgetary cutbacks from programmes directly or indirectly affecting children; they also request deliberate measures to protect the most vulnerable groups when implementing these belt-tightening fiscal measures. These calls, which we have heard before, forget that children’s’ votes do not count in the political equation – much less poor children’s’ votes. Selective, prioritized adjustments minimizing the human suffering of the destitute when budgets have to be slashed will not happen by good will alone, Political actions cannot be expected to acquire a human face just because we use convincing arguments based on ‘hard’ evidence. How many more children will have to die and live in misery for us to realize this – despite all our good intentions?
The Child Survival Revolution contains the seeds of partial success or partial failure. Are we still going to see health only for some by the year 2000?
The ‘Child Survival Revolution’ (CSR) is really only a reductionistic, second best approach to Primary Health Care (PHC) as defined in Alma Ata. It has chosen to emphasize the technological approaches of PHC, once again disregarding the structural conditions and processes that lead to seldom-diminishing morbidity and mortality rates amongst the poor in the Third World. Is this newest fad revolution, therefore, doomed? Is it just another gimmick to buy time? In the near future, we will certainly be pressed to differentiate between success and pseudo-success when beginning to evaluate results. It is not that the CSR will not save (some) lives, but is this going to be for good or just to preserve the child for yet another few weeks or months only to nave him die from another insult down the line? If we ask ourselves, realistically, why children are not surviving in the Third World, we are bound to identify immediate, as well as underlying and basic causes. Devising revolutions that only attack the first two, touching the latter only tangentially, is actually betraying the Alma Ata philosophy. Again, our health leaders have been blocked by an ideological straight jacket that has prevented them from leading us unequivocally towards Health for All by the Year 2000.
It is not the intention here to undermine the efforts by UNICEF and others in this area, but rather to put GOBI’s merits and demerits in the right perspective. Cautioning uncritical enthusiasts about the dangers and limitations of relying too much on GOBI as a technical solution to what is essentially a socio-economic and political problem is an urgent task as the eighties come to a close.
Is the Child Survival Revolution going to lead us to failure, as did previous non-comprehensive health care approaches? What is actually being questioned here is whether the Child Survival Revolution really addresses the root causes of child misery in the world.
Choices to seek or not to seek better health for family members are all intimately linked to the state of poverty of most potential beneficiaries of GOBI-FF and cannot be assumed to be made by the people in a vacuum. Some additional empowerment of the people is needed for meaningful choices to become realistic options; I am talking about having realistic choices that markedly affect the underlying poverty. Decisions of almost any kind are severely limited for the poor who lack access to a minimum income. They live unhealthy lifestyles because they are poor. Welfare and well-being is just more than mere survival… GOBI is touted as comprising actions that are all ‘low-cost, low-risk, low-resistance people’s health actions which do not depend on major economic and political changes’. They are, therefore, available now, we are told.
After 10 years of only rather marginal global achievements of primary health care, the best we have been able to come up with in the West seems to be GOBI-FP and the Child Survival Revolution which mainly took parts of the technical package of primary health care for intense, mostly top-down implementation. What was called a (mini)-revolution actually only took a combination of new technologies plus new means to communicate them (social marketing) and sold them to the international community.
So far, the experience has been at best a masquerading one; the Child Survival Revolution has vastly taken the existing social and political institutions as given in its approach and, thus, is partly responsible for ducking on the denunciation of the bigger, underlying issues leading to ill-health and malnutrition.
Moreover, certain themes re-emerge over and over when analysing the Child Survival Revolution literature: The need for political will, for social mobilisation, for involvement of the population, for changes in the health infrastructure, etc. However, all these concepts are used in a very inconsistent, demagogic, fuzzy. and empty way.
How can GOBI achieve real lasting progress when the pace of overall economic development in the Third World is slow or even declining? Improvements in health are bound to be limited if the macro-causes of ill-health are not tackled. Without changing the forces that give rise to and maintain poverty and an inequitable control over most resources, health promotion efforts in the Third World will necessarily be limited in their effectiveness.
GOBI is too strongly supply oriented, it tends to ignore the social constraints behind a weak demand for the effective utilization of existing or new health services.
We need to learn to live with the fact that health is not largely a function of the allocation of resources and investments. Primary Health Care means more than the mere extension of basic health services; much more. Those who overemphasize technologies and ‘professionalism’ thus serve spurious interests, not the people’s.
Too often, Third World countries end up following rules dictated from or set-up outside the country instead of evolving policies based on the country’s very own health and development needs.
It is important to note that Social Marketing has become a prominent component of GOBI and the Child Survival Revolution and deserves our scrutiny. Social marketing makes people mostly consumers, not protagonists and promoters. It is, therefore, not innocuous. It follows the basic principles of commercial marketing and can become an important inroad for the latter.
Giving people knowledge is not enough. Giving them access to significant remedial interventions, as chosen by them, is the key; and this is not what we are seeing happening. Too many false hopes are being placed on Social Marketing as a people-convincer and as a mobilizer for self-help in health endeavours.
There seems to be some evidence that people are ‘patterning’ their behaviour to what the provider wants from them just to receive the programme’s benefits.
Genuine participation calls for taking collective initiatives, following self-deliberation and self-managing the tasks initiated.
Access to the techniques of GOBI and the education that goes with it is not empowerment. It is rather a, keep them poor, but teach them attitude and approach.
Health services have to answer some important questions, instead of providing services mechanically, only quantitatively different from past (or colonial) services.
Health creation necessarily passes through wealth creation for the poor and the latter has to pass through increasing the power-base of the poor!
It is in great part up to us health professionals to create the necessary support systems. The people cannot always do this by themselves overnight, nor wilt they be able to in the near future, especially because of the mechanisms of (overt or hidden) repression in place.
We cannot depoliticize health in the search of a lasting solution. To do so is falling, over and over, in the trap of looking at it as a technical challenge at a time when we continue to experience deteriorating health statistics in the Third World.
Acknowledgements:
I would like to thank Rachel Schurman, formerly of the Institute for Food and Development Policy in San Francisco, for her contribution to this manuscript.
References
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Claudio Schuftan
Ho Chi Minh City, Vietnami.