17 de Abril: ¿Por qué no, “algo porque sí”?

This week, the La Paz daily La Prensa reported on four initiatives being undertaken in city of El Alto to combat tuberculosis (TB).  Luisa Mendizábal, the coordinator of the program, notes that El Alto saw 700 confirmed cases of TB in 2009.  One of the initiatives being used to combat the disease, however, has little to do with TB itself–instead, it uses pregnant women as, essentially, bounty hunters for potentially infected individuals.  The program is tellingly titled “Algo por Algo,” or “something for something”–as in, do something for us, and we’ll do something for you.

It works like this: if a pregnant woman brings an individual with symptoms of TB to her prenatal checkup, then she will not have to wait in line with the dozens of other expectant mothers to be seen.  Instead, she’ll pass directly through the double doors to see the doctor.  It bears mentioning that these women are forced to wait in line for hours because of their participation in another government program: the Bono Juana Azurduy.  As I have previously reported, the Bono Juana Azurduy pays pregnant women to go to state-run medical facilities for prenatal care and for the birth, rather than having their children at home.  While poverty has led expectant mothers to queue for hours to receive a bit of cash and what is often described as a cursory checkup, now Algo por Algo offers women the opportunity to cut down on their wait time by dragging a phlegmy, coughing, potentially TB-infected individual along with them.  Although TB is known to be contagious and potentially fatal, proponents of Algo por Algo are putting pregnant women at risk by giving them incentives to be in close proximity with infected individuals.

In part, I understand the impulse for programs like the Bono Juana Azurduy and Algo por Algo. Many women report being scared of health facilities, either because of their unfamiliarity, or because of the mistreatment that many have experienced there.  In the face of this fear, women often choose to have their children at home, where they are more likely to be attended in the birth by family members or by no one than by a midwife, whose services cost money.  The government officials who created the Bono probably genuinely hoped to reduce maternal deaths by getting women to the hospital.  (They also likely hoped to reduce the practice of traditional medicine and birthing methods.)  But programs like these are inherently flawed, for a number of reasons: they do not address the mistreatment that consistently drives women away from medical facilities, and they may expose pregnant women to TB, for example.

There’s another problem with incentive-based health programs, however, that I find much more fundamental: quality health care should NOT be something you get in exchange for something else.  Health care should be, and in some countries is, a basic human right.  A universal right. When reductions in maternal mortality or TB rates are achieved through cajoling and manipulation, rather than empowerment and education, I am uneasy to call this a true “win.” Rather than “something for something,” health care should be a question of “something just because.

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