-In public health, we uncritically assume scarcity of resources without asking why scarcity.
-WHO comes with technical advice, the World Bank comes with money….countries usually prefer the money.
D. The primary health care (PHC) perspective in right to health (RTH) work
18. Key to adopting the human rights-based framework in PHC work is to make it clear what we have to unlearn:
• that PHC is a first level, rural health service. It is a comprehensive and integral approach to people’s health;
• that PHC is primary and thus simple. It rather is essential, non-negotiable basic front-line care;
• that PHC is about relations between human beings. It also is about relations with nature and with the local ecosystem;
• that PHC is a system for the care of sick people while they are sick. It is a system to accompany healthy persons and persons with health problems all the way;
• that the differences between cultures are to be found in behaviors and attitudes. Differences are mostly about values;
• that intercultural means people with different backgrounds living together. It means the different cultures have to dialogue with each other; and
• that we have to try to change the behavior of people. Instead, we have to dialogue with them. (Julio Monsalvo)
19. For the latter to become a reality, PHC programs must respect local environments, cultures and the different organizational forms/patterns that communities have adopted locally.
20. For long, PHC has been misunderstood; it has sunk to its lowest when governed by ‘The Rule of 3’: 3 questions, 3exams, prescription for 3 medicines, in 3 minutes, or when ‘sustainable misery packages’ have been offered to people who live in poverty while the non-poor are given an array of choices.
21. As is well known, PHC has also suffered from a verticalization of health programs that do not adequately acknowledge and tackle the structural dimensions of poverty thus betraying the real spirit of the Alma Ata Declaration.
22. When such a misconstrued PHC has embraced some health promotion activities (rarely), it has concentrated on changing individuals’ behaviors with –as expected– exceedingly limited effectiveness. That is not where promotion efforts are needed on a population basis. (Vicente Navarro)
30. When PHC is targeted to cover ‘the poor’, it is exclusionary and reinforces existing social stratification and stigmatization. Targeted programs also often involve greater administrative costs and are prone to leakage. (Chantal Bloiun)
31. Greater cash transfers to PHC will not work if the health system remains primarily curative and top-down in scope and is not ready to improve the quality of preventive, promotive and rehabilitative services.
32. It is fitting here to mention that off-budget health spending, as the one we have been seeing for AIDS, TB and malaria, fragments national health policy making with diminished attention being given to strengthening the infrastructure of a comprehensive national PHC system.
E. Privatization from the human rights perspective
-The private sector is like a tiger: it needs to be put in a cage (not too small, not too big). (Olof Palme). We need it to do what it does best –which is not the provision of health care since it does it expensively and dishonestly.
33. Privatization of health care is a class policy, because it benefits high income groups at the expense of the popular classes. (V. Navarro)
34. Moreover, the privatization of services that is being pushed is about curative care, not about preventive and promotive care; the latter two –and the curative care of the poor– are graciously left to the public sector. So, since privatization’s consequences on people who live in poverty are well-known, the commoditization of health is simply unacceptable for human rights activists. (This is not only a matter of principles, but of evidence!). What this means is that the Right to Health Care (RTHC) is non-negotiable. If it is to be a right, health is not a marketable commodity… and a human right it is!
35. Commoditization brings about, for instance, the excesses of insurance companies in the health sector that too often are supported by fiscal policies –from tax exemptions to tax subsidies– which explains why they have increased exponentially over the years. To be noted here is the lesser known fact that pharmaceutical houses are also supported by tax money.* (V. Navarro)
*: This diverts public funds or resources that might otherwise be available to fund frontline public services.
36. The privatization drive we here summarily present is ongoing. A snapshot shows that the public sector is grossly under-funded and over-worked whereas the private sector is grossly inefficient and inequitable… and is nevertheless still blindly courted by big funders like the World Bank. (G. Mooney)
37. The World Bank’s ideologically driven search for market-led policies as a means to resolve gaps in health care has led to the contradictory position of promoting policies that research shows to be ineffective. The problem is that they often transfer ideological norms and organizational paradigms from the developed to the developing countries. For instance, contracting out services (“steering rather than rowing”) is part of their current economic and public management philosophy. (John Lister and Ron Labonte)
38. Bottom line, private involvement carries large overhead costs and simply needs to deliver some form of profit. There is thus simply an insurmountable gap between public interest and private privilege. Only through putting pressure on the state will the excesses of the private sector in health be eventually done away with. (Abhay Shukla)
Claudio Schuftan, Ho Chi Minh City
cschuftan@phmovement.org