We have tried to demystify medical care and decrease the control of the medical profession and instead promote the paramedic, the village-level health worker, as the backbone of health care.
Acceptance speech – Zafrullah Chowdhury / Gonoshasthaya Kendra
Honourable Members of the Right Livelihood Award Committee,
Members of the Swedish Parliament,
my Fellow Awardees,
Colleagues and Distinguished Guests.
We are honoured to be here today to receive the Right Livelihood Award on behalf of Gonoshasthaya Kendra.
Health is a basic right of all persons. Gonoshasthaya Kendra has struggled long and hard to ensure that right and deliver quality health care to the people. This Award comes at a time when we are faced with renewed threats. Your recognition of our work gives us strength and the inspiration to continue.
1. I would first like to say a few words about the situation of health care in Bangladesh and Gonoshasthaya Kendra’s work.
Health has not been a priority in any of Bangladesh Government’s Five Year Plans since Independence in 1971. National investment in health is around 2.5 % of the total annual allocation. This is of course not adequate. But the sum total of foreign grants and national investment over the last twenty years exceeds billions of dollars. This investment has not improved the health of the people. At the same time expectations for health care has increased. This failure is due to the fact that we have not developed an integrated health system where preventive, promotive, rehabilitative and curative care services including family planning and health education work together to achieve better health care. Instead, donor pressures have led to expensive vertical interventions such as the Expanded Programme for Immunisation (EPI), Family Planning, etc each having a separate establishment.
There are more than 18 000 doctors in Bangladesh. In addition, there are more than 100 000 community level extension workers involved in different vertical programmes under health and family planning. There is no relationship among them at the service level. As a result, infant mortality remains between 110-140 and maternal mortality over 6 per thousand live births.
2. Gonoshasthaya Kendra (GK) was established in Savar in 1972 to deliver basic integrated health care in the rural areas. The mainstay of GK’s health care delivery system rests on a team of paramedics, “barefoot doctors”, most of whom are young rural women. Through them health services have reached rural homes and the poor in particular have been able to gain access to medical services, health education and essential drugs. Each paramedic has responsibility for 3,000 people for whom they provide a wide range of basic health services. They register births and deaths, they identify high risk pregnancies, provide ante-natal and post-natal care, immunize, treat common ailments like diarrhoea, scabies, acute respiratory infections, provide health and nutrition education and teach the preparation of oral rehydration saline. They also perform minor surgery and take care of normal births. They have referral links to secondary care clinics and GK’s hospital.
Paramedical training is a continuous part of Ego’s efforts to build trained health personnel from within the ranks of the rural poor. Basic training takes 6 months, after which paramedics learn on the job and through continuing practical lessons.
I share this honour here today with my paramedic colleague, Rezia Begum. Rezia comes from a poor rural family which could not offer her the privilege of education or the prospect of an income earning skill. She has been with us nearly 10 years starting as a paramedic trainee. Today she is a Union In-Charge, responsible for the health of 20 000 people.
3. Although Gonoshasthaya Kendra’s health programme aimed to provide domiciliary health care to rural poor households on a priority basis, we soon found that women were not attending to their own health needs nor their children’s. Indicators for children’s health showed a high incidence of prolonged morbidity and mortality from diarrhoea, pneumonia and other infectious diseases, and a high rate of maternal mortality among women. On querying as to why they did not avail of clinical services at earlier stages of the symptoms, it was found that most women depended on male members of their households to escort them to the health centres. The fact that women rarely possessed cash money further restricted their ability to avail of clinical services. It was clear that, if Gonoshasthaya’s health programme was to achieve any sustainable impact, women had to be involved in education and earning. The oppression that women face in a conservative rural society and the increasing trend of insecurity in marriage meant that more and more women found themselves in helpless situations without any non-familial institution to turn to.
4. GK has succeeded in breaking social barriers and creating a training environment conducive to women’s confidence building. From its very inception GK has pursued a policy of positive discrimination for women in its staff recruitment. As a result, the majority of workers in GK are female, creating a naturally friendly and congenial surrounding for women, many of whom are stepping outside their villages for the first time. At the same time that women predominate in all activities of GK, there is no sex segregation in any sphere. Women and men work together in workshops, offices, clinics and in daily agricultural work. Male and female residential quarters are not separated by boundary walls.
5. GK’s philosophy of people’s health care has two main pillars:
i) the participation of ordinary rural people, especially women, in the delivery of health care; and
ii) the village level application of scientific innovations and the transfer of knowledge of simple treatments to semi-literate persons.
We have tried to demystify medical care and decrease the control of the medical profession and instead promote the paramedic, the village level health worker, as the backbone of health care. This has led to both capability building and job creation for the poor, especially poor women, as well as reach health benefits to those who have not in the past had the access of the means to health care. Nationally this work influenced the government to include paramedics in their health and family planning programme and also influenced the government to increase opportunities for women in other sectors.
6. Twenty years after the establishment of GK, the well-being of the people of the programme area has improved considerably. They have access to cheap, integrated health service resulting in decrease in mortality and birth rates, reduction in infant mortality to 65 per thousand live births and maternal mortality to between 1 and 2 per thousand live births, and over 80 % immunisation coverage.
7. Bangladesh adopted a National Drug Policy in 1982 based on the World Health Organisation’s recommendations on essential drugs and rational use of drugs. Gonoshasthaya Kendra established its own pharmaceutical factory in 1981 and played a pivotal role in the formulation of the National Drug Policy. When the policy was introduced it faced threats and pressure from multinational corporations, interested foreign governments and ironically from our own medical community. Ten years later the policy has effectively contributed to price stabilisation and net decrease in price in the case of many products, growth of pharmaceutical production in the country, improved quality and widespread availability of essential drugs. However, the pressures to dismantle the policy continue unabated and have found a new lease of life in the current policy environment of deregulation and economic liberalisation.
Today the achievements of the drug policy are threatened by trade interests with the support of World Bank policies. Recently, in a letter from the World Bank’s Industries Division* a number of recommendations have been made to our government to remove restrictions on drug lists, pricing and control on advertising. Policy packages designed for promoting incentives to the producers should not be at the expense of curbing the interests of the consumers. Drugs can not be put in the same category of consumer goods as clothing and food products. Every drug has side effects and variable uses, and should be used with extreme caution. Economic liberalisation does not mean that dismantling of regulatory frameworks, particularly for public goods. The kind of total deregulation being proposed by the Bank will on the on the one hand destroy local pharmaceutical production, and on the other increase drug prices considerably beyond the reach of the majority of the people. Drug companies can not be given carte blanche for production and marketing.
8. Bureaucratic strangle-hold over industry is a major concern for most Third World countries including Bangladesh. However, because of the radical drug policy in Bangladesh, bureaucratic incursions on pharmaceutical manufacture has been greatly decreased and consequently there has been a six-fold value wise growth of drug production. The increase in volume of production is even greater. The Policy has introduced competition among foreign drug manufacturers in Bangladesh. Consequently, they are producing more antibiotics and hormonal preparation instead of tonics and vitamins. As a result, quality antibiotics are available at cheaper rates. Withdrawal of sub-standard drugs through public announcements in the press is part of the transparency introduced by the Policy. Further transparency is needed in the case of annual production of various drugs, especially tranquilizers and other addictive drugs. Medical reasons for the introduction of new drugs have to be given along with cost consideration.
9. Promotion of essential drugs and regional drug use by world health bodies, such as WHO, is being directly contradicted and undermined by ‘international development institutions’ such as the World Bank in its prescription for market-led efficiency through deregulation. What is needed is a transparent regulatory framework not deregulation, whereby transparency of drug administration and the industry will be ensured, which in turn will enhance consumer understanding about drug safety, cost effectiveness and rational prescriptions.
10. Although the Drug Policy has achieved a lot in the way of affordable quality drugs, the health sector as a whole continues to paint a dismal picture of negligence, inefficiency and malpractice, and governance by centralised bureaucratic administration with no public accountability. Seventy percent of the doctors work in urban areas serving only 20 million out of the total population of 110 million. The remaining 30 % are not all available in their rural duty stations. Consequently, 80 % of primary health care hospital facilities remain unutilised whereas urban hospitals are overcrowded. On the other hand, hundreds of private clinics have mushroomed in urban areas without being subject to regulation and quality supervision. These clinics survive on malpractice, fraud and prescribing unnecessary drugs and diagnostic investigations. Public hospital doctors are engaged in private practice and many work in private clinics neglecting their duties in the public hospitals.
11. The National Drug Policy has led to tremendous growth of private enterprise in pharmaceutical manufacture while also benefiting consumers through cheaply available high quality drugs. A National Health Policy could have similar far reaching impact by incorporating decentralised primary health care as articulated in the Alma Ata Declaration, with referral facilities to secondary and tertiary care hospitals. Public accountability with public participation and medical audit would ensure quality and lower total costs. Such a policy would lead to real growth of private health care and at the same time public health services would improve.
12. We have had to pay a high price for our achievements. Besides the everyday hostility our workers and the institution has faced from vested interests and social conservatism we have also suffered major wounds. In 1976, one of our paramedics was murdered; in 1984 our pharmaceutical factory was attacked. This has not stopped our work. Yet what we have not achieved is vital. Our struggle for a National Health Policy has met with opposition and hostility and in 1990 several of our offices were attacked and burned. Assassination attempts and threats is also a part of our experience.
13. Health economy does not necessarily mean health of the people. Just at the time when my government is being commended for good macro-economic performance, a study on rural poverty trends shows that 48 % of all households are subject to downward mobility pressures arising out of illness-related crisis.** Macro-economic indicators do not tell us about the impoverishment that can result from a simple episode of illness because services are not within the reach of these people.
The pitfalls of “modernity” in the health sector can be exemplified by the import of powder milk. Bangladesh imports every year over 5 billion Taka’s (USD 125 million) worth of powder milk from EEC countries, Australia and New Zealand. This contributes not only to poor nutrition and ill health but also destroys the prospect of local dairy development and the employment potential it has.
14. I want to take the opportunity of standing before you today to raise the issue of global patenting, an issue which is not only of concern to us in Bangladesh, but to all those struggling to sustain the livelihood of the Third World.
Inequality is on the increase everywhere in the world. The divisions of North and South, rich and poor, women and men continue to deepen. The push for global patenting will exacerbate these inequalities and inhibit the development potential of our countries.
15. One of the worst affected is the prospect for health care of our peoples. In most Third World countries, including India, affordability of drugs is already a serious problem and over 50 % of the population do not have access to modern health care. In Bangladesh, 25 % of the population do not have an opportunity to see a doctor even before they die.*** Cost and availability of drugs is critical. Yet, if patenting is permitted local production of drugs will be cut down and both affordability and availability of drugs will decrease drastically.
The pharmaceutical industry comprises of two major components – the production of basic ingredients and the formulation of drugs with basic active ingredients and excipients in various forms such as tablets, capsules, injectables, liquids etc which are marketed in different brand names.
Innovations in active basic ingredients in the field of pharmaceuticals have been very few and usually limited to what can be described as slight variations in chemical composition. Research facilities of multi-national pharmaceutical companies are located exclusively in the developed countries. For the most part, these companies have not installed production facilities in Third World countries, not even for formulations – an activity which contains hardly any novelty.
In other words, intellectual and financial investments of multinational corporations in Third World countries is very much limited or at best negligible. Under such circumstances, the justification for the extension of “First World” patents to “Third World” countries has to be challenged.
Process patent refers to methods involved in the production of basic ingredients. Process patent may be justified but should not extend beyond ten years in countries where the company concerned establishes production facilities for the manufacture of basic active ingredients.
16. Furthermore, there is no rationality what so ever for patenting of brands. Product patent is nothing but the patenting of brand names. The central problem of product patent is that it deters the replication of necessary products which are produced and in circulation under different brand names without paying royalties. Names of formulated products (Brand and Branded Generic) may be registered under the Trade Marks regulation but should not be patented as there is no real innovation involved. Product patent is nothing but the neo-colonial extraction of tolls from Third World countries in favour of multinational corporations. When these countries are not directly benefited why should they be taxed in this manner? Empires have ended but imperial exploitation continues through the modern transnational.
The introduction of product patents will effectively destroy the nascent industrialisation process in third world countries. Indigenous methodologies will be subjugated and eventually destroyed by technologically advanced nations. Prices will increase and artisans and cottage producers in the Third World will be robbed of the ability to invent, innovate and reproduce.
The possibility of simultaneous or independent discoveries in several parts of the world should be recognised. The Third Worlds of course further disadvantaged in this race. The discoveries of artisans and inventors located in remote settlements without either the communication links or the commercial knowledge necessary to compete for patent rights must not become discredited by such incursions. In many of our cultures production, innovation and the creation of knowledge is not concomitant with the notions of possession and property that form the basic premise of the Intellectual Property Rights discourse.
Most of the newer drugs entering the market are revised permutations and combinations of the earlier generation of drugs. If someone independently arrives at a revised and/or existing formulation drug why should this be prevented by Product Patent?
17. In the South we do not patent medicinal plants and herbs, yet research on these is patented in the North. We have for decades handed over our genetic resources, without further claims to scientists and research bodies of the North. Any indigenous product from these resources are also subject to infringement of patents of the North. Moreover, there is no acknowledgement or credit given to the centuries of indigenous knowledge of plants and botanical resources. It is this indigenous knowledge which has enabled northern scientists to carry our their research. There has also been a migration of intellect and scientific capability from the South to serve academic and industrial institutions of the North. All these have contributed to the research directly and indirectly.
18. Patenting, is therefore not only an issue of economic survival of southern countries; whether patents can be imposed in spite of our contributions through knowledge, plants and our scientists and technicians working in the North is also a moral issue. There is an urgent need therefore to question the legitimacy of patents and to rethink the universal and uniform applicability of patents. The task before all of us here, in the South and in the North, is to organise resistance to the imposition of the existing concept of Intellectual Property Rights used in World Bodies. It is not only detrimental to the peoples and economies of Third World countries, in the long run it will undermine the prospects for global harmony and “one world”, and slowly kill the aspirations of the common people all over the world that had been created by the advancement of science.
*Letter from Mr. Abid Hasan, Chief of the Industries Division, World Bank to Joint Secretary, Economic Relations Division, Ministry of Finance, Government of Bangladesh dated 9 June, 1992.
**Re-thinking Rural Poverty: A Case for Bangladesh, ed by Rahman, H.Z. and Hossain, M., BIDS, Dhaka, January, 1992.
***Khan, M.R. et al, BIDS, Dhaka, 1985.
Dr Zafrullah Chowdhury
P.O. Nayarhat Via Dhamrai
House 14 E, Road 6