What are the issues?

We foresee ut leust two lssues thut should be consldered. The flrst ls the potentlul of such developments to lmprove
the quullty ln heulth cure wlthln the world. The second relutes to lssues of uccess to heulth cure und the ethlcul
dlmenslons ussocluted [6].
Developlng lnternutlonul stundurds ln medlcul educutlon und heulth cure dellvery cun help lmprovlng quullty ln
heulth cure ull over the world. Nevertheless, two questlons remuln. To whut extent cun one be sure thut lnternutlonul
stundurds cun be creuted thut wlll flt the culturul, soclul, und economlcul contexts of very dlfferent countrles? It ls
often ussumed thut, slmply demonstrutlng compllunce wlth quullty processes, wlll leud to u result (of the educutlon or
of the treutment) thut wlll be the sume, whutever the country or the professlonuls lnvolved. But to whut extent cun we
be sure thut upplylng,
The second questlon ls wlll udoptlng such unlversul stundurd contrlbute to the lmprovement of uccess to heulth cure
uround the world? Slmpllstlcully, one mlght urgue thut slmply lowerlng the cost of heulth cure would glve wlder
uccess to cure (heulth cure dellvery would beneflt u wlder runge of people und/or u wlder runge of cure would be
offered to people). But thls hus to be nuunced.
We huve to conslder who mlght beneflt most from thls new sltuutlon. Flrstly, the putlent muy huve llttle to suy ln
where, when, und how thelr cure ls provlded, glven the prlorlty of flnunclul lssues ln the strutegy of heulth cure
orgunlzutlon. Addltlonully, we cun usk, how wlll we know lf he or she reully recelve equlvulent cure ut u lower prlce?
Further, ethlcully speuklng, lt ls not ucceptuble to exclude the locul populutlon from the beneflts of cure thut ls
provlded ln thelr country for rlch strungers, even lf thls orgunlzutlon ullows less rlch countrles to develop
employment ln the heulth cure sector. Flnully, there ls un lnevltuble und negutlve lmpuct on employment ln the heulth
cure sector of the rlch countrles who export thelr putlents.
Achievements and opportunities
Tremendous developments in health information technology have been recorded in recent years in the
context of globalization. Sharing and comparing health information, increasing communication through
the internet, the use of telemedicine are all but some of the far reaching developments in the
application of ICT in the health sector. Telemedicine in particular has increased the potential for
improving access to care by underserved populations and point the way to a future when distance will
no longer impede care. For instance, the last three decades saw the number of transistors on a chip
increasing from 2300 to over 40 million in the Pentium 4 processor.
1
During the same period the cost of
computer technology went down from US $ 760 per MHz of speed and $ 5257 per Megabyte of storage
to a mere US Cents 17. Similarly, tremendous development occurred in communication technology
where the cost of transmitting a trillion bits of information went down from US $ 150,000 in 1970s to US
Cents 12 in 1999.
2

These developments have brought opportunities for enhancing the quality of life by increasing access of
medical knowledge and state of the art medical interventions to health workers. In Europe patients
carry a card-sized CD that carry information on medical information ranging from charts, laboratory
results and x-rays pictures.
3
Personal Digital Assistants (PDA) have been used by nurse midwives in India
resulting into the reduction of paperwork, increase data accuracy and ensured availability of data in
electronic form.
7
It is now possible using Personal Digital Assistants (PDA) to transmit data through
wireless communication and enter it into database using Internet.
4

In the US, over 50% of patients have access to email leading to increased communication with their
doctors hence improvement in patient-provider relationship.
5,6
In Japan, over 50 percent of physicians
were reported to use Internet to access medical information.
7
Reports shows that Internet connection in
Africa is showing promising growth with a rise from only 12 countries in 1996 to almost all countries
now.
8

The New Africa Initiative (NAI) adopted by OAU aimed at doubling the teledensity to two lines per 100
people by the year 2005 with a focus on developing local content software based on Africa's cultural
systems. It seeks to promote cross-border cooperation and connectivity by utilising knowledge currently
available in the continent.
3

Furthermore, reforms in various sectors have resulted into deregulation and privatization that has
created conducive environment for competition thus increasing demand for new services especially ICT.
9

Access to ICT
The distribution of benefits from ICT that created global imbalance is most glaring. Whereas global ICT
market has surpassed US $ 2 trillion in 1999 and expected to reach US $ 3 trillion by 2004 developing
countries accounted for a mere 2% of the revenues.
3
In developing countries, communication of
information is limited by unavailability of broadband access and where this is available it is too
expensive for the majority to afford.
7

There is a big divide even among developing countries. In Africa, a continent where 12% of the world
population (780 million) lives, ICT products and services are scarce and expensive. And where the
services exist, they are often erratic and unreliable. Africa is therefore a poor player with little
information of its society shared in the worlds ICT market. Even within Africa the disparity is very
obvious. For example South Africa account for almost 90% Internet hosts of the total in Africa, followed
distantly by Egypt (3%) and Botswana (1%).
3
Tanzania along with other 46 countries in Africa share only
2% of Internet hosts. It has the less international bandwidth than Sao Paul, Brazil.
10
Of the 400 million
Internet users in the worlds in the year 2000 less than 500,000 were in Africa.
The same picture applies to telephone line, mobiles and PCs density. Africa has less than 2% of the
worlds' telephone mainlines amounting to 10 million in 1999. Although mobile cellular telephones have
grown very fast in the past 5 years and are now available in 42 countries; outside South Africa, they
account for only 20% of total phones in the continent.
3
. The latest edition of the UNDP Human
Development report shows that in 1999 coverage of cellular and fixed phones in Ghana, Kenya and
Uganda were 15, 11 per 1,000 and 5 per 1,000 respectively. The average was about 6 per 1,000.
11
In
Tanzania less than 10 per 1,000 have telephone lines.
12

The enormous social and economic disparity between the urban and rural areas where more than 85%
of the people resides pose a special challenge in developing countries. Computer and communication
technology in urban areas of developing countries is advancing very fast threatening even a wider digital
divide internally. In these countries it is not uncommon to find sophisticated technology such as oil
refineries and modern aircrafts alongside disease and poverty.
13
The abject poverty in a country like
Tanzania where 38.7% of rural population lives below poverty line makes any attempts to redress this
situation a formidable task.
18
In India, a project that attempted to provide access to Internet in 70
villages had cost about US $ 600,000, which proved to be beyond the capacity of the country to afford.
7

(j) Personal services and activities of extra-territorial organisations and bodies


Competing interests
TOver the last three and a half decades or so, one of the most striking phenomena globally has been
the emergence of the medical industry as the second largest industry in the world, after arms. This
period has also seen the world becoming richer than it has ever been in the past. Yet health of the
population globally has been either stagnant, or in large parts of the world, actually decelerating.
This might seem paradoxical to some who see health as an outcome of interventions in the medical
sector alone, for what it does reveal is that there is no necessary connection between medical
expenditure and advances in medical technology and population health. But for those who are
familiar with the work of Mc.Keown and others, this should come as no surprise. What is surprising,
however, is the severe backsliding in population health globally since the world took a turn, in the
late nineteen seventies, to the second phase of globalization. This is reflected in stagnation in health
indices with widening health inequalities in the US and UK, a health crisis of huge proportions in
the countries of the former USSR, stagnation of health indices in large parts of the world such as
India and China, and deceleration in many indices in many countries of Africa and Latin America.
This paper briefly traces the trajectory of this second phase of globalization, and how this contours
and determines health outcomes. The famous sociologist Anthony Giddens defines globalisation as
the intensification of worldwide social relations which link distant localities in such a way that local
happenings are shaded by events occurring many miles away and vice versa (Giddens 1990:64).,
This definition of globalisation has become extremely popular and has been cited extensively.
However what this definition does is to naturalise the process of globalisation and thus depoliticise
it. Globalisation, in this definition, is much like the weather; there is little to be done but suffer the
consequences. Natural, it appears there are in fact no institutions and human actors who are guiding
this process to their gain, but to the increasing marginalisation of millions. Human beings, as long
as they have lived on earth have jn fact been global creatures, moving around the world, trading and
learning and interacting. But from the seventeenth century arose a new manifestation, that of
colonialism. Colonialism is often referred to as the first wave of globalisation and contributed to the
most significant feature of the global economy today: The division between the First World, of, by
and large, colonial nation and the Third World, of colonized ones. Colonialism set the structures for
the global transfer of resources from the global South to the global North, that has accelerated in the
second phase of globalization. Since the end of the Second World War, as the colonized countries
liberated themselves from direct colonial rule, they attempted with limited success, but with success
nevertheless, to make a break with historical structures of global inequity underlying their
underdevelopment. As a result of such policies as self-reliant import-substituting growth, there was a
reduction in the flow of resources from the countries of the Third World to those of the First. In other
words, there was a decline in the rate of exploitation of the former, as they protected themselves
from, and attempted to recover from, the ravages of globalisation, militarily imposed, that they had
been victims of for centuries. This was in most cases partial, and half-hearted, but nevertheless real.
There was thus reversal of secular historical trends in food availability, in value added in production,
in per capita incomes and so on. At the same time, there were efforts to provide a modicum of
health, nutrition and education. Reflecting all these changes there were improvements in health
indices as life expectations increased, the morbidity and mortality rates declined and birth rates
increased. The second wave of globalisation was initiated after 9/11 / 1973 in Chile, with the
overthrow and murder of its democratically elected President, Salavador Allende. The essential
elements of the package of neo-liberaljsm were field tested, at the behest of the Chicago school of
economists, Prof. Milton Friedman and Prof. von Hayek in particular (who of course went on to win
the Nobel prize in economics), with the political support of corporate capital in the USA, the religious
right-wing, and the CIA (Grandin 2006) The post-oil price hike tremors in the financial markets were
the immediate provocation for the launch of the global neo-liberal project. Economists hesitated to
use the word depression to describe this phenomenon, the new global recession, since it brought
back painful memories of the 1 930s, a period that had plunged the world into the horrors of fascism
and the Second World War, but the recession of the 1980s was similarly widespread and deep,
with equally profound social consequences. These changes took place together with the collapse of
the Soviet Union and the state controlled economies of the socialist world, as the Berlin wall
crumbled and the world turned upside down, They also led to a reshaping of the capitalist world, not
in the direction of the new international economic order envisaged by the Third World at the time of
the Bandung conference but in a diametrically opposite direction. The new world order that was
actually created led to a complex of changes known as globalisation, privatisation and liberalization.
As the long boom of the post-War golden age of capitalism ground to a crisis, this period was
marked by the rise of right-wing monetarist regimes in the USA and the UK, along with the
domination in the belief in what Hobsbawm describes as ultra-liberal economic theologians,
whereby the ideological zeal of the old champions of individualism was now reinforced by the
apparent failure of conventional economic policies (Hobsbawm 1994: 409) Neo-liberal economic
policies, described variously as Reaganomics, Thatcherism, corporate globalisation or monetarism,
reflected an ideological commitment to unbridled market principles, ignoring the remarkable role that
the state had played even in the advanced capitalist countries. One of the significant lessons of post-
War economic growth had been the singular role that the state could play, and indeed needed to
play, in capitalist countries to avoid recurrent periods of crisis due to falling demand. For instance,
state involvement in public health had been considered critical, as state provision of public goods
was also at the heart of the strategy to stabilize the economies and to increase productivity; In the
new environment these Keynesian policies increasingly came under fierce attack. This new
consensus shared a profoundly cynical view of the state, especially in the developing countries,
although neo-liberal free-market rhetoric often contrasted sharply with the actual practices of the
Reagan and Thatcher governments in their own countries where the state was increasingly
subsidizing the rich (Gershman and Irwin 2000), Reducing the role of the state and increasing that of
the market, irrespective of their social and indeed long-term economic costs, was thus at the center
of this model of therapy. Economic growth, it was maintained despite extensive evidence to the
contrary; would trickle down to the less fortunate and thus result in overall development. At the
height of economic and political power in the new uni-polar world, the United States found a way out
of the impasse of falling rates of profit and increasing unemployment within its shores by opening up
potential markets in the third World countries. The debt situation of these countries itself a product
of First World lending policies in the past became the vehicle for introducing these measures in
countries, now subject to a colonial onslaught. Future loans from international financial institutions,
and access to donor funds and markets became linked to accepting this broad package of
macroeconomic policies under the rubric of the Structural Adjustment Programme (SAP). This also
provided the rich countries of the world to increasing and increasingly cheaper access to
resources of the world, even as it reinforced the international division of labour. Deflation,
liberalization and privatization were applied in a uniform measure across Latin America and Africa in
the l980s in what has been widely described as imperialist globalization (Patnaik 1999)., In the
agricultural sector, this led to the reinforcement of colonial patterns of agricultural production,
stimulating the growth of export-oriented crops at the cost of food crops. The problem at the heart of
this pattern or production is that it was implemented at a time when the prices of primary
commodities were the lowest in history; Indeed by 1989, prices for agricultural products were only 60
per cent of their 1970 levels (Hartmann 1995). Thus the more successful these countries were in
increasing the volume of exports, in competition with other Third World countries exporting similar
products, the less successful they were in raising foreign exchange to finance their imports. It is not
surprising that many countries shifted back in time to being exporters of unprocessed raw materials
and importers of manufactured goods, albeit with a sharp deterioration in the terms of trade against
developing countries in general and agriculture in particular. Unable to compete with highly
subsidized agriculture in the developed world, peasants throughout the Third World have been
plunged into debt and despair. In the industrial sector, where developing countries had teen striving
to break out of colonial patterns of dependent development, the withdrawal of state support plunged
many enterprises into crisis, leading to deindustrialisation. Such units were then allowed to close, or
were privatized, or handed over to trans-national corporations, typically with significant Losses of
employment (parr 1994). Just as the state reduced its commitment to critical sectors such as
education and health, so also the flow of capital across borders in search of labour, raw materials
and markets, indeed the frenetic search for quick profits, typically weakened the state. Further, over
this period, capital across the globe was concentrated in fewer and fewer hands, with an implosion
of mergers and acquisitions. The driving force behind this phase of imperialist globalization is
speculative finance capital, not related to manufacturing or trade, or indeed to the metropolitan
nation state, but instead opening up the world in a quest for greater profits (Patnaik 2003). Together
these policies and processes increased indebtedness of the third World countries that they were
supposed to reduce, increased the rate of exploitation of wage- workers across the globe, and
shifted wealth from productive to speculative sectors. The policies also led to the increase of casual,
poorly paid and insecure forms of employment. Fund cuts in education and health also meant that
already weak and under-funded systems of health, education and food security collapsed. It is thus
not accidental that these policies increased levels of poverty in already poor countries even as a
small section of the population became richer; this section of the middle and upper classes obtained
access to consumer goods hitherto available only in the rich countries. Gershman and Irwin note that
the involvement of the World Bank and the IMF in moulding the policies of countries in Latin
America, Africa and parts of Asia expanded dramatically in the 1980s: by the end of 1991, 75
countries had received structural adjustment loans worth more than the equivalent of 41 billion
dollars (Gershman and Irwin 2000). At the same time, the debt of the developing countries soared
from 658 billion dollars in 1980, to 1375 billion dollars in 1988, to 1,945 billion dollars in 1994 (Report
of the Independent Commission on Population and Quality of Life 1996). One important
consequence has been commonly described as the feminisation of poverty as women increasingly
had to strive to hold families together in various ways in the face of increasing pressures, chief
among them increasing poverty and insecurity. In many countries, more women entered the labour
force but typically at lower wages and with inferior working conditions than for men; in many others,
women were displaced from employment as levels of unemployment increased markedly.
Simultaneously, the extent of unpaid labour in households, performed largely by women, increased
as public provision of basic goods and services declined. Young children, especially girls, were
increasingly withdrawn from school to join the vast and grossly underpaid informal labour market or
to assist in running the household. Rising food prices, along with cuts in subsidies for the poor,
meant that an increasing proportion of families with precarious resources were pushed under the
poverty line, affecting women and girl children disproportionately. This also meant an increase in
young women and indeed women in general-being pushed into the sex industry, now increasingly
global. It is not surprising that studies indicate that under these conditions hunger and morbidity
levels increased, even as poor people were increasingly unable to access health institutions, which,
under the reform measures, typically introduced fee for services. Given increasing levels of under
nutrition, infant and child mortality rates, which had hitherto shown a secular decline, either
stagnated or in the case of some countries, actually increased. So unambiguous and deleterious
were these changes, and so extensively documented, that even the UNICEF issued calls for a
human face to structural adjustment program me. The World Bank did, in the face of these
challenges, make some changes. These took three forms: a prescription for labour intensive growth;
investing in the poor via the development of human capital chiefly investments in health and
education; and finally, the promotion of safety nets and targeted social programmes. In other words,
there is an implicit recognition that specific programmes are necessary to protect the poor from the
consequences of structural adjustment and that growth by itself does not reduce the problem of
poverty. But this re-thinking was seriously limited. The Commonwealth Secretariat, for instance,
observed: any benefits women may have attained from compensatory measures have been only
incidental. They have not prevented devastating setbacks in crucial areas such as maternal and
child health services, basic education and training, child care, and the provision of credit, extension
and other support services to help women as producers (Commonwealth Secretariat 1989: More
significantly, between 1990 and 1993 sub-Saharan Africa alone transferred 13.4 billion dollars
annually to its creditors, substantially more than it spent on education and health combined. From
1987 to 1993, the net transfer of resources from Africa to the IMF was 38 billion dollars (Gershman
and Irwin 2000)! Yet, of course, the problem of poverty is almost invariably placed at the door of
population growth. Increasing inequalities in income, in health, and so on were also distressingly
apparent in other countries that had followed similar economic trajectories. Indeed they were also
increasingly visible among the poor even in the developed countries. In a number of the developed
industrial countries, mortality differentials rose sharply in parallel with widening disparities in socio-
economic status (Dvey Smith and Egger 1993). Significant reversals in health status were also
observed in the newly independent states of Eastern Europe (WHO 1998), Sharp declines in life
expectancy have also been recorded in countries of the former Soviet Union, involving a health
crisis of unforeseen proportions in the Russian Federation(Evans, T, Whitehead, M.,Diderichson, F.,
Bhuiya, A., and Wirth, M. (Eds) 2001: 3). Thus it is that these two decades have often been
described as lost decades. Structural adjustment programmes, then, did not reduce debts, cut down
levels of poverty or return countries to a path of growth. The external debt stock of developing
countries increased from 616 billion in 1980 to an estimated 2.2 trillion at the end of 1997. Yet at the
same time, the flow of resources to rich countries actually increased, as indeed they were designed
to. In 1960, the poorest 20 per cent of the global population received 2.3 per cent of the global
income. By 1991, their share had sunk to 1.4 per cent. Today, the poorest 20 per cent receive only
1.1 per cent of global income. The ratio of income of the wealthiest 20 per cent of the people to that
the poorest 20 per cent was 30 to 1 in 1960. By 1995, that ratio stood at 82 to 1. This is based on
distribution between rich and poor countries, but when the maldistribution of income within countries
is taken into account, the richest 20 per cent of the worlds people in 1990 got at least 150 times
more than the poorest 20 per cent (UNDP 1992). The 20 per cent of the worlds people who live in
the highest income countries account for 86 per cent of the global consumption; the poorest 20 per
cent, only 1.3 per cent. In other words, while the world had grown incomparably richer, the wealth
generated had been distributed remarkably unequally. Not surprisingly, it has been argued that
globalisation is really about the expansion of TNC activities to the developing world on TNCs terms
(Raghavan, C. 1996: l3) and that globalisation is proceeding largely for the benefit of the dynamic
and powerful countries (UNDP 1997). It can also perhaps be described as a neo-colonial marriage
between metropolitan financial interests and metropolitan industrial interests (Patnaik, p. 1999).
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Press, Stanford, Ca. 2. Grandin, Greg (2006). Empires Workshop: Latin America, the United States,
and the Rise of the New Imperialism, Metropolitan Books, New York. 3. Hobsbawm, E.J. (1994) Age
of Extremes, Viking, Delhi. 4. Gershman, John and Irwin, Alec (2000) Getting a Grip on the Global
Economy in Jim Yong Kim, Joyce, V.Millen, Alec, Irwin and John Gershma, (Eds) Dying for Growth:
Global inequality and the Health of the poor, Common Courage Press, Maine. 5. Patnaik Prabhat
(1999) The Political Economy of Structural Adjustment : A note in Mohan Rao (Ed) Disinvesting in
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historic Alma Ata Declaration of 1978. It was not soon however before both these organization,
turned their backs on this, when they backed selective primary health care, and were soon to be
swept by the wide ranging changes in the health care sector initiated by the World Bank. By this time
of course, the World Bank had emerged as the major actor in setting the agenda for international
health care policies, For instances, World Bank loans on one programme, for malaria eradication,
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Patnaik, Prabhat (1999) op cit.he author(s) declare that they have no competing interests.