World Bank Induced Primary Health Care User Fees in Punjab, India

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Sign on campaign demanding abolition of User Fee charges for the poor in

World Bank funded state health sector in Punjab, India

In the mid 1990s, the World Bank provided a loan to India to create the

Punjab Health Systems Corporation (PHSC). At the time, the Bank claimed the

program would promote transparency, accountability, and efficiency in the

health care system; and that the project would pay significant attention to

the needs of women and the poor. In reality, the project has far from lived

up to intentions. Most significantly, the PHSC project mandated the

application of user fee charges to those in need of medical services

regardless of patients' income levels. Marginalized groups, chiefly the

poor and women, have faced severe hardship in receiving medical attention,

because they cannot afford to pay the user fee charges as required for

health assistance.

In theory, the poor are exempt from the user fees charged for medical care.

However, exemption mechanisms have failed to ensure the poor and women's

access to health care in Punjab, as well as in other Indian states that

have implemented similar World Bank projects. Exemption entitlements have

also been ineffective and counterproductive in Mali, Zimbabwe, and Ghana

where World Bank sponsored user fees have also been imposed.

In the case of the Punjab Health Systems Corporation, poorer patients must

request a 'yellow card' from the government in order to have the user fees

waived. Yet most poor patients are not even aware of the exemption card. If

they are aware, then the complex and costly procedures required to obtain

and retain their exempt status still excludes most of them from receiving

medical attention. As a result, they have to pay a user fee in addition to

bribes (to doctors, nurses, and other hospital staff) so that they might be

treated. In early 2001, only 44 'yellow cards' were distributed in a city

of about 270,000. This has led many poor people to seek medical care from

unqualified persons, using superstitious methods of treating medical problems.

Therefore, INSAAF International in India has launched a campaign, forcing

the World Bank and PHSC to acknowledge and rectify the vast gap between

their stated policy goals and the realities of its implementation.

Moreover, in September 2001, after years of pressure by NGOs and citizen

groups, the World Bank was forced to change its policy on user fees, to

forbid the imposition of user fees on access to primary health care. This

change in policy must be applied to all of the World Bank's existing and

previous projects, such as the PHSC project in Punjab.

In February 2002, INSAAF International released a report documenting the

effects of the World Bank sponsored corporatization of Punjab's health care

system. India Together, a web magazine has summarized the report in the

adjoining article, " Yellow Cards for the Poor " .

http://www.indiatogether.org/health/reports/insaaf01.htm

Please support INSAAF International's efforts by participating in a

signature campaign for the letter being sent to the World Bank and the PHSC.

- Vineeta Gupta, General Secretary, Insaaf International,

vineetag@...

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LETTER

Please send your sign - ons to Shrayas Jatkar at shrayas@...

Mr. Wolfensohn

President

World Bank

1818 H Street, N.W., Washington, DC 20433

U.S.A

Special Secretary Health cum Managing Director

Punjab Health Systems Corporation,

S.C.O 341-42, Sector 34A

Chandigarh, INDIA 160022

Dear Sirs,

The orders of the World Bank-funded Punjab Health Systems Corporation

(PHSC), Punjab, India to hike the user fee for health services and

elimination of subsidized fee structure for low income group is clearly

another example of the insidious World Bank strategy of charging the poor

when in fact its mission should be to deliver them services they could not

otherwise afford.

India is a welfare state, and the National Health Policy (NHP) emphasizes

the role of the state in providing basic health care. The objectives stated

in the project under which PHSC was created were to improve efficiency in

allocation and use of health resources through policy and institutional

development, improve the performance of the health care system, increase

coverage and effectiveness of services at the primary and secondary levels,

and to better serve the neediest sections of the population. But

practically it is resulting in denial of the right to health and

undermining state responsibility in providing basic health care to its

citizens. The poor and women are worst hit with the increased costs of the

treatment.

This is being done at a time when even the U.S. Congress has passed

legislation that strongly opposes this practice and when the World Bank

itself supposedly opposes user fees on primary health care. We strongly

condemn PHSC for its anti poor and anti women policies.

We demand that these orders be reversed immediately.

Sincerely,

Dr. Vineeta Gupta

General secretary, INSAAF International,

Punjab, India

Email guptahr@...

Please add your name to the letter by sending your sign-on to

shrayas@...

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