People that happen to be poor need jobs and a livelihood;
to agonize about inequality is, for them, a luxury. (M. Klein, World Bank)
1. Both Structural Adjustment and the forces behind Globalization have fostered a polarization in a direction opposite to greater equality in health and thus opposite to the human right to health (RTH).
2. Levels of income are lower today in more than 70 poor countries than in the 1960s. The chronic stress arising from the resulting social exclusion is as damaging to health as are meager income and poor access to services. Today, around 1.3 billion people still survive on less than $1 a day. Inequalities in health manifest themselves primarily in decreased access and utilization of services by people who happen to be poor. In this respect, 1.6 billion people are worse off today than they were 30 years ago. But these indicators only tell part of the story of inequality; we do not routinely measure other.*
*: Here is another piece of information you may use: The richest 1% of the world’s adults, 60 million people, with assets at least half a million dollars, own 40% of the global assets/wealth.
3. Our inaction on equality and RTH issues is explained by pure procrastination; we simply cannot ignore the underlying power-play-of-politics behind inequality since this would denote ‘evidential nihilism’ (M. Petticrew); we simply have to deal with the underlying power issue.**
**: We note here something that has become one more of those iron laws, namely that maintaining things the-way-they-are requires no good reasons but, when presenting a better idea, efforts to shut it down brings-on tons of ‘reasons’. (Aldo Caliari)
4. Globalization does not have a human face; power differentials are at its crux. It is a process we cannot wish away. Markets reward those with purchasing power or commodities or services to sell; people and nations that happen to be poor have neither.
5. At a time of shrinking government expenditures in health in those countries, the World Bank has them pushing for a greater role of market forces in the production and distribution of health: the solution is to commercialize, commoditize and privatize health. Market forces alone (with people paying for their own care) have failed to deliver minimum acceptable health care anywhere. Because people are already paying for care, the WB assumes people are willing to pay. But willingness does not mean ability!
6. In the fee-for-service system, equality is clearly being sacrificed in the name of a not-yet-proven-greater-efficiency. Providing health care on the basis of need is being replaced by a system based on a never-really-achieved cost recovery where exemptions targeted at poor people have not worked. Safety nets are nothing but a way to manage poverty and ‘ill-being’ (as opposed to wellbeing) by attenuating social unrest.
7. Therefore, health policy makers can no longer make decisions that conflict with the equality goal. The choice is a moral one and cannot be made by the medical establishment only. The politics of health will override all other efforts to bring us Health for All and respect for the RTH. (Keep in mind that equality is the forgotten central thrust of Alma Ata).
8. We need to develop a framework for action; the costs of inaction are enormous. We also need to demystify medical knowledge –for people themselves to deal with health and disease.
9. It is in the interest of the RTH to counter the forces of Globalization rather than looking for an accommodation to-fit-greater-health into an inherently-inequitable-system. This means that a renewed commitment and resolve to foster empowering community-based activities will have to guide our actions. What will count are not our words, but our deeds. Growth and equality need not be trade-offs, but progress does not come simply from liberalizing the economics of health. The current brand of liberalization is morally unacceptable and economically inefficient. We need to adopt new approaches that can break the current unequal state of affairs. Claim holders have to stop thinking that combating inequality is a luxury.
10. Perhaps the most pressing issue for claim holders to work towards the RTH is for them to demand a universal coverage public health system in which those who pay for it are those that have more, i.e., a progressive (as opposed to a regressive) tax-based system.
Claudio Schuftan, Ho Chi Minh City
cschuftan@phmovement.org