"The Role of Government" -- by John Hammock

Up until just a few weeks ago, growth, spurred by the private sector and the market, was the centerpiece of development thinking. If you believe that growth in the economy will benefit everyone in the end, why would you need government services to serve the poor? Well, hand in hand with an unwavering faith in economic growth has been a move to “let the economy do it.”

There has been a full frontal attack on the role of the state—by those who believe that privatization is best and government should downsize. These suggestions have been made where healthcare has been concerned and it has not worked. The Millennium Project points out that for the last 20 years there has been a focus on the producer-consumer, privatized and fee-for-service model to improve systemic health care issues. Governments have asserted that there would be programs to help the most poor to procure healthcare, while others would buy healthcare services. However, this has not been effective at providing health care for all and one of the major barriers facing women who die due to maternal health issues continues to be access to affordable healthcare. Subsequently, the Millennium Project advocates making fundamental changes to the way health care reforms have been conceptualized by highlighting the importance of government.

The state is the only body that can look beyond private interests and keep an eye on the needs, rights and responsibilities of all citizens. It does not have a mandate to profit and should not become tired of serving the public. It is the responsibility of the state to regulate corporations and ensure that society is meeting the needs of all its members.

Government has a strong role to play in poverty reduction. This flies in the face of the dominant neo-liberal economic ideology that calls for government to cut services and to downsize. Some suggest that civil society can pick up the slack where governments have become inactive. That’s misguided thinking. Private charity, including Church charirity, is not enough—not enough money and not enough sustainability. NGOs do not have the resources that governments do. Additionally, they do not often have country-wide strategies for poverty reduction, rather they are locally based or focused. One NGO, with the best of intentions, may arrive in a country and build a number of clinics in one area and another NGO may come in and build a few clinics in another area. While it may be positive to increase the number of clinics in a country, this activity could be inefficient or scattered and thus ineffective. If NGOs are not working as part of a coordinated health approach that helps to meet an overall strategy for health care in the country, their activity may not be meeting the country’s needs. And this coordination must come from a national or state body has that has political legitimacy.

Additionally, if NGO, church, corporate or individual efforts to help others is based on benevolence or charity, it’s going to work for a day or two and maybe even a number of years. However, when that NGO, corporation or individual gets tired of giving, decides it wants to give for something else or its donors pull the funds, then the charity is going to end and those resources will leave. And then what? Do we just tell a community that its healthcare isn’t important enough to sustain? So the issue is how to build programs that are sustainable over time. The answer is to work to ensure that governments have the ability to strengthen and sustain their own systems and to provide the policy incentives and frameworks for private as well as public services. Yes, this is harder than just donating money to a local nonprofit. Yes, this is a mind change about working with governments rather than only putting our faith in the private sector—profit or non-profit.. And yes, it’s easy to say and incredibly tough to do. However, if real change is going to occur, it’s what we have to do.

Governments do not have to be wealthy to provide the context for human development and services that will cut poverty and help to meet the Millennium Development Goals. Money is important, but it is not the only thing required. Government will and policies are as important, if not more important, than funding.

Maternal mortality is highest in sub-Saharan Africa and Central Asia and lowest in industrialized countries like the United States. However, one shouldn’t assume that just because a country is in the Global South, it is destined for a high maternal mortality rate. The case of Cuba, a country with 33 maternal deaths per 100,000 live births, when other countries in Latin America are in the 100s, shows that it is possible for a developing country to successfully implement a maternal health strategy. It is hard to use Cuba as an example, since political ideology gets wrapped up into the discussion before one even finishes mentioning the country’s name. And we are certainly not advocating for the Cuban system of government. However, Cuba has done a good job at using limited funds in a way that responds to maternal health needs. In 1990, when the Soviet Union fell, Cuba lost its largest trading partner as well as a large amount of economic assistance, totaling an estimated $4 billion to $6 billion annually. Although the government cut its overall spending dramatically, it did not drop education and health completely and still considered health a priority for the country’s budget. It’s expenditure of 6.5% of GDP on health shows political will to keep the health system strong. Other countries that spend 6.5% of GDP on health include Canada and Switzerland. Political will and resulting government decisions on money, even in poor countries, can greatly impact maternal health and social services in general.

1 UN Millennium Project, Who’s Got the Power, 39-41.
2 Ibid., 109.
3 See Ibid., 102 for a chart on the renovations of country health systems that are suggested in order to make systems work better for maternal health.
4 See statistics for individual countries at UNICEF, Information by Country, Statistics Pages: http://www.unicef.org/infobycountry.
5 United States International Trade Commission. The Economic Impact of U.S. Sanctions With Respect to Cuba, Washington D.C., February 2001, USITC Publication 3398, 3-8 (78). http://hotdocs.usitc.gov/docs/pubs/332/pub3398.pdf. (Accessed December 23, 2005.)
6 Acosta, Dalia. 2002. “HEALTH-CUBA: Maternal-Infant Mortality Down Despite Crisis.” Inter Press Service, January 16, 2002. http://ww2.aegis.org/news/ips/2002/IP020103.html. (Accessed December 23, 2005.)
7 United Nations Development Program. Human Development Report 2005: International Cooperation at a Crossroads: Aid Trade and Security in an Unequal World. “Human Development Indicators: Table 6: Commitment to health: resources, access and services,” 236.
8 Ibid.