On July 13, the U.S. House of Representatives passed its foreign operations appropriations bill.  After much debate, the bill included nearly the full amount President Clinton requested for the joint IMF/World Bank "debt relief" program, the Heavily Indebted Poor Countries (HIPC) Initiative.

  The bill also contains a provision that represents the first attempt by Congress to use its leverage over the IMF and World Bank to stop some of the worst aspects of structural adjustment ˜ in this case, the imposition of user fees for primary health and education.   The House bill still has to be reconciled with the Senate version, so it‚s not yet law, but it has cleared some of the most difficult hurdles.

  The 50 Years Is Enough Network and other organizations worked closely with Rep. Jesse Jackson, Jr. (D-IL), who introduced the anti-user-fee amendment to the bill in the House Appropriations Committee.

  We have long objected to the HIPC program‚s linkage of debt relief to structural adjustment programs (SAPs).  We did not oppose the appropriation included in the legislation, but we remain committed to working for debt cancellation that frees countries from the shackles of IMF/World Bank demands.  The user fee provision is a modest first step in that direction. It does not satisfy the need for a complete divorce from structural adjustment, but it can contribute to saving and improving lives.  It is also a significant first penetration of the seemingly-invincible armor SAPs have been accorded by the IMF, the World Bank, and the powerful governments that control them.

  We will also continue to advocate for debt cancellation that requires the international financial institutions to write off debts rather than demand that Northern countries pay them off with their taxpayers‚ money, as is the case with the HIPC program.

  Under the provision adopted by the House, beginning in 2002, U.S. funding would be provided only when the heads of the World Bank and IMF certify their institutions "will not include user fees or service charges through Œcommunity financing,‚ Œcost sharing,' Œcost recovery,‚ or any other mechanism for primary education or primary healthcare, including prevention and treatment efforts for AIDS, malaria, tuberculosis, and infant, child, and maternal well-being" in any of their programs.

  User fees, charges imposed for using a health clinic or attending school, have led to increased illness, suffering and death when people cannot pay for health services, and decreased school enrollments when poor families can no longer afford to send their children to school. In a tragic example in Zambia quoted by UNICEF, a researcher observed a 14 year boy with acute malaria turned away from a health clinic for want of a 33 cent registration fee. According to the report, "within 2 hours, the boy was brought back dead."

  Recent studies have revealed some of the damage done by user fees imposed by IMF/World Bank structural adjustment programs:

• In Kenya, introduction of a 33 cent fee for visits to outpatient health centers led to a 52 percent reduction in outpatient visits. After the fee was suspended, visits rose 41 percent. 
  
  
• Introduction of user fees at rural clinics in Papua New Guinea led to a decline of about 30 percent in attendance, and although it subsequently increased it never returned to pre-fee levels. Health workers also reported a reduction in completion rates for courses of treatment.
  
  
• In Dar es Salaam, Tanzania the three public district hospitals saw attendance drop by 53.4% between the second and third quarters of 1994, when user fees were introduced.
  
  
• In Nicaragua, about a quarter of primary schoolchildren have not enrolled in primary school since charges for registration and a monthly stipend were introduced.
  
  
• In Niger, cost recovery measures implemented as part of a structural adjustment program between 1986 and 1988 had the following results: 1) a sharp decline in already very low primary school enrollment rates: these went from 17% in 1978 to 28% in 1983 to 20% in 1988; 2) drop in utilization of preventative care services; 3) increased exclusion of the most impoverished from care at Niamey Hospital, where outpatients who did not pay for care would wait an average of 24 days before seeking care while an outpatient who did have to pay for care would wait an average of 51 days; and 4) exemption systems that were applied to the benefit of urban, military, and civil service families and not for the intended beneficiaries (the most impoverished).
  
  
• UNICEF reports that in Malawi, the elimination of modest school fees and uniform requirements in 1994 caused primary enrollment to increase by about 50 percent virtually overnight - from 1.9 million to 2.9 million.  The main beneficiaries were girls.  Malawi has been able to maintain near full enrollment since that time.