What Rights are at Stake in Structural Adjustment Programs?

Alex Shoebridge examines the complex relationship between structural adjustment and the causes of poverty.

For 60 years now, the Universal Declaration of Human Rights has explicitly enshrined the right to adequate health care. Article 25 states that: “Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing, medical care and necessary social services.” However, the right to adequate health care, particularly maternal health care, is compromised by the implementation of ‘Structural Adjustment Programs’ imposed by international financial institutions.

This article looks at maternal health care because it provides a microcosm for examining issues that can apply generally to both the right to health care, as well as the right to development. Maternal health care is linked to several other signifiers of development, including education and health, as well as broader cultural, economic and social rights. Uganda and Indonesia will receive particular attention, as both nations have adopted policies in line with structural adjustment, with consequent effects on the availability and quality of maternal health care. Notable differences between rural and urban areas, as well as public and private health services, illustrate the implications of structural adjustment on maternal healthcare outcomes.

Mazur observes that structural adjustment has generally had a negative impact on the right to development, of which maternal health is an implicit factor. The provision of rights has traditionally been a state role, as reflected by the fact it is states that are signatories to treaties such as the Universal Declaration of Human Rights and the International Bill of Rights. However, the effectiveness of the state is reduced by the imposition or grudging acceptance of structural adjustment programs.

“Structural adjustment “add[s] to the structural causes of poverty” by continually alienating the poor and making them increasingly vulnerable.”

As Ben Thirkell-White observes: “The state is compelled to make decisions that are not based solely on the will of its own political community,” and implement budgetary constraints and limited government spending in accordance with the conditionality of such programs. Thus, the ‘hollowing out’ of the state has reduced the capacity of public programs to meet the needs of the nation’s population. These processes have manifested themselves in the decentralisation of policy implementation, as well as the privatisation of important social services such as health and education. This creates disparities along income levels as well as urban-rural divides, leading to inequality in both the accessibility and quality of such services. As such, structural adjustment “add[s] to the structural causes of poverty” by continually alienating the poor and making them increasingly vulnerable.

The right to maternal health care highlights the wide-ranging effects that structural adjustment has on the broader right to development. Differences between rural and urban maternal mortality rates, inaccessibility to appropriate medical facilities and the nature of these facilities (private, private-not-for-profit or public), are indicative of wider trends in development. They also highlight potential inequalities and areas of public or private failure. Thus, the effect of structural adjustment on maternal health care in Uganda and Indonesia suggests broader systemic implications for the development prospects of these nations.

In 1999, in an attempt to recover from decades of corrupt rule as well as the Asian Financial Crisis, the Indonesian government underwent sweeping decentralisation. In the period known as Reformasi, the government legislated to decentralise (Law 22/1999 on Regional Government and Law 25/1999 on Fiscal Balance between the Region and the Center) with the aim of creating a more efficient, higher-quality public service. As noted by the Asian Development Bank, it was hoped that decentralisation would create quasi-regional autonomy, which would then lead to better outcomes in terms of the provision of social services. Since 2001, both the Abdurrahman and Sukarnoputri governments have displayed a willingness to implement reforms in line with structural adjustment. However, due to the strict conditionality imposed by donors and the International Monetary Fund, as well as a significant budgetary deficit, government expenditure is considerably limited. This in turn affects the ability of local provinces to provide vital services to their constituents, due to a lack of federal funding.

“The importance placed on the private sector, as well as the public-private partnership, means that there are inevitable inequalities in the distribution and quality of health.”

While the decentralisation and distribution of health officials across Indonesia has positively impacted on maternal health care, systemic problems exacerbated by structural adjustment continue. Estimated public health expenditure in Indonesia is lower than in other low-income countries, and there is a significant onus on private medical facilities. Estimates vary across different international organisations: the Asian Development Bank estimates public health expenditure to be 1.6 per cent of Gross Domestic Product, while the World Health Organisation estimates it to be 2.8 per cent (the WHO average for Low-Income Countries is 4.5 per cent). Despite these cross-institutional variances, it is widely recognised that the level of government expenditure in Indonesia is insufficient to achieve progress in health.

Meanwhile, in 2004, private expenditure accounted for 65 per cent of total expenditure on health. As Makoweicka et al. suggest: “There exists a substantial wealth gradient and urban/rural split … in both maternal mortality and uptake of skilled attendance.” While the national percentage of births with a medical attendant in 2006 was 72 per cent, this does not reflect the regional disparities and inequity in available resources. Maternal mortality in Indonesia remains internationally high (UNICEF estimates it at 420 deaths per 100,000), but can be significantly reduced by the effective distribution of skilled health workers (such as midwives).

Limited government spending means that many poorer communities are without maternal health care facilities, while the wealthier and predominantly urban areas have access to private means. In 2005, for example, WHO estimated 262 maternity deaths per 100,000 on average nationally, while the figures for Papua in 2003 show an even higher rate: 396 per 100,000. This suggests the possible limitations of the private sector, as well as illustrating the chasm between rich and poor that is accentuated by structural adjustment.

Uganda is often lauded as one of Africa’s economic success stories, having achieved real GDP growth rates of over five per cent since the launch of the IMF-supported Economic Recovery Programme in 1987. Despite this success, the gains of development have not been evenly distributed. Similarly to Indonesia, structural adjustment in Uganda has resulted in trade liberalisation, the discontinued support of inefficient industries as well as the reduction and decentralisation of public services.

“Limited government spending means that many poorer communities are without maternal health care facilities, while the wealthier and predominantly urban areas have access to private means.”

This has exacerbated regional and income inequalities. As Morrissey et al. suggest, economic liberalisation led to the market provision of services in urban areas, while in rural communities, poverty is not improving. The long-term conflict occurring in the northern parts of Uganda has undoubtedly accounted for a lack of health care services in this region, although with increased expenditure, government provision may have been more effective.

These general, regional disparities, affected by limited government expenditure, have had severe implications for the provision of maternal health care. Estimates of the maternal mortality rate in Uganda vary from 846 to 505 deaths per 100,000 live births between 1988 and 2001, and reflect the disparities between rural and urban areas. The importance placed on the private sector, as well as public-private partnerships, means that there are inevitable inequalities in the distribution and quality of health services. As Ssengooba et al. find, “out-of-pocket spending contributes between 58 – 75 per cent of total health care financing in Uganda”. Such significant fees, according to Chaudhury et al., often act as a deterrent to using such treatment and immediately alienate poorer users who cannot afford such facilities.

As such, relatively high-income regions of the country are serviced by the private sector, illustrating the discriminatory nature of private health care and the subsequent inequity of its distribution.

The structural adjustment programs adopted by many low-income countries in accordance with donor and IMF conditionality have significantly compromised human rights within these nations. Structural adjustment programs impose strict conditions that include limitations on public spending, while encouraging the decentralisation and privatisation of social services. As seen in the cases of Indonesia and Uganda, this results in the inequity of service provision and quality, due to the influence of private facilities or public-private partnerships. Due to the limited role of the state in this process, rights are jeopardised. Increased income inequalities and regional disparities have significantly affected maternal health care in these two nations, creating a further chasm between the rich and the poor and adding to the structural causes of poverty.