Global health care reform began with a structure that included locally held values and important community-focused mechanisms in a format referred to as the Alma Ata strategy, named for the meeting place of the World Assembly in 1978 (Janes 458). The Alma Ata strategy was criticized widely early on and was eventually replaced by a strategy more focused on economic factors, which Janes refers to as the World Bank model.
In particular, Janes uses the example of post-socialist Mongolia as a region straddling a local-global divide where the new global economy has left important local issues regarding health care by the wayside. His research in Mongolia exposes the overall breakdown of an economics-based approach to global health care reform.
Western medicine and health care reform push traditional non-Western beliefs aside as governments and economies operate in new global fashions. Janes argues that the new primary care model does little except provide poor medicine to poor people (458). Changing economic values and ideologies have negatively affected the participation in funding health care for citizens in countries throughout the world; those in poorer countries or communities being more negatively affected than others. He also discusses the issue of community participation in health services.
For success at the local level, for health care to operate effectively, community buy-in, belief, and involvement is necessary. Global programs fail to involve local participation, instead focusing on the diseases, especially epidemics, themselves.
Janes’ skills as an anthropologist equip him to look closely at the effects of the new era of global health reform from a social perspective rather than simply an individual, biomedical, or economic perspective, where local social effects have been largely ignored (459). Since the end of the Alma Ata days, the World Bank has been the single most influential power in global health care policy. The World Bank approach is that “diseases are more important to address than the people who contract and suffer them” (460).
This approach has left the system segmented and broken, forcing small-time local doctors to act as true minimum service providers, who can offer only the lowest possibly services and preventative measures, and become essentially a referral service to the more expensive specialists in the secondary and tertiary levels of the health care paradigm.
As stated above, Janes’ work was focused specifically on Mongolia, where he operated alongside specialists with backgrounds in economics and epidemiology to obtain a more accurate, locally-focused analysis to provide a better understanding of the barriers to effective health care access. An important measure for him to consider in Mongolia was health care equity with regard to social justice, or notions of fairness, and economics, or distribution of resources. Janes describes three key socioeconomic processes that influence health care equity: vertical equity, horizontal equity, and fair protection.
Vertical equity refers directly to the distribution of money and resources to pay for the health care of all citizens. Horizontal equity refers to a needs-based approach to health care access. Fair protection refers to the equal right of all families and individuals to protections from catastrophes, including catastrophic illnesses.
Janes conducted a series of interviews with over 500 Mongolians to determine the effectiveness of health care reform in post-socialist Mongolia based on the equity measures described above. What he found was a sharp divide between how the system was intended to perform and how it was actually performing. Some of the more important discoveries included that insurance was regulated poorly and provided incomplete health care costs (even at a basic level), family doctors were little more than a referral system for more expensive and non-guaranteed specialty services, and ancillary costs, such as transportation costs and hospitalization fees, were not covered by insurance.
Janes states plainly that the current system in Mongolia, despite being designed to provide care for all, is largely violating the basic tenants of health care equity. He says, “the burden of health care costs are unfairly shared, health resources are unfairly distributed in the community, and individuals and families are vulnerable to the potentially impoverishing consequences of sickness” (462). Though everyone has access to insurance, not everyone is insured, and those that are may not actually have access to the services they actually need, such as those services typically performed by a specialist.
What Janes brings to the table as a medical anthropologist is a way to bring the local focus back into the global scene. He does this through the applied anthropological method of applying a conceptual framework to the existing scenario. This conceptual framework revolves around collecting local knowledge and beliefs to be able to focus on local behavior patterns and ethical values, and thus any fieldwork conducted must focus on the needs of the local community. For example, medical anthropologists must consider the social consequences of illness on individuals and families, which may intertwine with economic and other factors, and leave the intricacies of the illnesses themselves to epidemiologists.
Ultimately, work such as Janes’ is important to bring the human element back into an innately human problem. And while his work is nearly 10 years old, we see these problems continue to exist worldwide today. Indeed, the political debate over Obamacare in the U.S. has sparked the conversation over similar access to healthcare in the West. Despite what many non-governmental, private, and special interest organizations, universities, and foundations may portray, the problems facing health care reform are very basic in nature. As Janes’ points out, the “grand challenges in global health are not, as Bill Gates would have us believe, related to technological roadblocks” (263).
Janes does not state that he has all the answers, nor does he hint that he will have them; but he emphasizes that it is the anthropologist’s job to ensure that a multilevel approach to global problem solving is put forth, that the local is not forgotten when thinking about the global, and that multiple discipline approaches are used to solve social problems. Anthropology must remain true to form -observant, analytical, aware, and critical - to truly affect positive social change.
Janes, Craig R. “Going Global in Century XXI: Medical Anthropology and the New Primary Health Care.” Human Organization. Vol. 63, No. 4 (2004): 457-471. Print.
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