Forgiveness of debts: A recipe for health care
TB controllers need to speak up, expert says
To advocates of debt relief, it all boils down to simple math: Subtract the burdensome debt payments that will siphon $13.5 billion from sub-Saharan African economies this year, and you’ve instantly added resources for strengthening desperately needed health care services, they say.
As basic as that sounds, the concept of debt relief — the cancellation of huge debts incurred by poor nations in the 1970s and 1980s — has yet to catch hold of the popular imagination in most places. One well-known American TB expert recalls talking to the head of a highly placed World Health Organization program director about the AIDS epidemic rampaging through Africa. "There’s simply no money for treating AIDS," the program director declared.
"Well, but what about debt relief?" asked the TB expert.
The response was less than heartening. "Debt relief?" echoed the puzzled program director. "What’s that?"
Widespread response needed
Public health advocates in this country need to become better informed on the subject and speak up about it, says Jim Kim, MD, executive director of Cambridge, MA-based Partners in Health (PIH). "One or two people talking about this isn’t going to be enough," he says. "It’s important for all of us to learn about this issue."
To do some consciousness-raising on the subject, RESULTS International, a grass-roots advocacy group that has taken up the cause of TB, recently held a press conference about debt relief. Featured speakers made up a lively and somewhat unexpected mix, including Jeff Sachs, PhD, director of Harvard’s Center for International Development; Bono, lead singer of the Irish rock group U2; and U.S. Congresspeople Spencer Bachus (R-AL) and Barbara Lee (D-CA).
"Debt relief is the most greatest moral and social issue of our time," says Bachus. "These debts were, in many cases, loaned to dictators, and the people in the countries never benefited from the money. Instead, the debts have basically destroyed the health care and educational systems of those countries."
So far, debt reduction programs have managed to write off about 27% of debts in 22 countries, but the gesture hardly counts because the written-off debts were those not being paid anyway, notes PIH’s Kim. Fresh analyses of "debt sustainability" offered by the International Monetary Fund and others as proof of their good intentions amount
to little more than diversionary tactics, argues Sachs, because the analyses have "absolutely zero to do with what is really sustainable for these countries."
User fees: The cruelest cuts
Last year, Bachus and his colleague Lee succeeded in getting language included in the federal foreign-aid appropriations bill that would prohibit one of the cruelest features of the debt-payment system: the user fees levied by poor countries for basic health and education services. Euphemistically labeled health-care "reform," user fees are an important part of the fiscal-restructuring policies that indebted poor countries must agree to implement to keep the credit flowing.
The rationale for user fees is that they strengthen health care systems and make them more sustainable, says Kim. In reality, they rarely accomplish that goal, but instead cause droves of poor people who can’t afford the fees simply to stop seeking health care. The Bush administration has indicated that it opposes eliminating the fees, notes Joanne Carter, director of RESULTS.
On the other hand, when user fees are eliminated and debt payments even modestly reduced, poor peoples’ lives improve dramatically. In Honduras, for example, modest debt relief has enabled the government to offer three more years of free school. Mali, Mozambique, and Senegal have used savings from debt relief to increase spending on HIV programs, and Uganda has doubled primary-school enrollment while reducing HIV transmission.
Because the International Monetary Fund (IMF) and the World Bank continue offering new loans to pay off old debts, there’s still a long way to go, say debt relief advocates. Astonishingly, for every dollar sent in aid sent to poor countries, $1.30 flows back to lenders in debt payment services.
Making sure indebted countries use debt forgiveness for health care (as opposed to, say, weapons purchases) shouldn’t pose an insurmountable problem, adds Kim. "The IMF and other multilateral lending institutions have a long history of placing conditions on loans," he says. There’s nothing stopping them from "conditioning" debt relief, he says.
Bringing more debt relief to poor countries is, simply put, the American way, says Bachus. "We say we want to bring freedom and democracy to these countries," he says. "But we can’t do that if they’re starving and dying."
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