1. Our collective destiny is not in our hands. It is in the hands of a handful of powerful agencies over which we have no control. It is our respective governments that appoint the country’s representatives to these international decision-making bodies (which often do not even have a ‘one-country-one-vote’ modus operandus). Each government instructs their reps on the position they should take (very rarely pertaining to human rights issues), the tactics they should use and the votes they should cast; and it is each government that is empowered to remove them should they fail to fulfill their responsibilities.
2. Since electorates typically have almost nil influence in this international decision-making –while the corporate sector has much stronger and more direct interests– the agenda of international organizations is increasingly skewed strongly in favor of corporate interests which reflect only a window-dressing-interest in human rights (HR).
3. Moreover, since the proceedings of the WB and IMF Boards, for example, are confidential, this means that only governments know their votes were affectively used, allowing them to operate with zero accountability to their electorates for the positions they take. These interests, which too often regrettably clash with HR, are nationalistic in nature, primarily promoting national commercial and financial interests and pursue geopolitical and ideological agendas. This, rather than seeking the greater common good, in our case HR. It is nor surprise, then, that this results in a system oriented to the promotion of the interests of the rich*
*: Very few people do the following calculations. But be educated: To double the income of the poorer 10% of the world’s population without any redistribution of income would require 100% economic growth, i.e., doubling global production and consumption and dealing with the catastrophic associated environmental costs. At a growth rate of the GNP of 3% per year the process would take 24 years. Alternatively, the same result could be achieved immediately by redistributing less than 1/3 of 1% of the income from the richest 10% of the world’s population to the poorest 10%. Does this tell us something?
4. As regards WTO agreements, the same end up being given precedence over other agreements, including those directed towards protecting human rights or achieving social and/or environmental goals. Under such constraints, policy makers in health become ‘policy-takers’ who must adapt to the effects of trade agreements, i.e., ultimately, health policy ends up being made to fit trade agreements which is nonsensical.
A crisis of capitalism?
5. We have so many times said that people in the North desperately need to take responsibility for their historical and present contributions to climate change. But it actually also is the whole process of Globalization that is, in good measure, responsible for the climate crisis. Why? Because the climate crisis is a crisis of over-consumption; conversely, the development crisis is a crisis of under-consumption! As you know, Globalization creates powerful emerging markets and –let us not overlook– submerging markets that struggle to keep their heads above water as the rising tide of global economic growth conspicuously fails to lift all boats. This results in the fact that it is income and wealth that are, these days more than ever, the fundamental determinants of social status and self worth. Increasingly, the financial tail is wagging the economic, social and political dog. The overall and HR disaster this creates is now history.
6. For too many decades, the global economic system is grounded firmly on capitalist principles, on booms and busts. The most recent financial crisis has clearly demonstrated its failure either to satisfy the most basic needs of most of humanity or to operate within the confines of environmental sustainability.
7. The current crisis of the global economy is actually systemic and demonstrates the non-viability of capitalism in its current form, characterized as it is by extreme inequality, HR violations and poorly regulated markets, as well as dominated by the interests of a small rich minority embedded in the corporate and financial sectors.
8. If we want to achieve social and HR goals such as health for all, poverty eradication, universal education… i.e., the fulfillment of human potential –and to do so while simultaneously tackling climate change and achieving true environmental sustainability– then we need to redesign the global economic system to realize these aims. We cannot simply assume that these goals will somehow magically be achieved under an economic model designed to achieve fundamentally different and, in many respects, contradictory goals. The maximization of production and of consumption –implemented through grossly undemocratic decision-making processes in the interests of those with the greatest power and the greatest resources– spells disaster.
9. Like it or not, this is what has brought us to the current situation, one that is characterized by multiple crises. We cannot realistically expect more of the same to get us out of it.
Repercussions on Primary Health Care
10. Although several global health initiatives have brought welcome increased funding for priority diseases, they have at the same time reinforced the selective approach to health care by privileging vertically implemented and managed programs that mainly emphasize therapeutic and personal preventive interventions while significantly neglecting upstream determinants of these diseases, i.e., we are (and have been) faced with a phasing-in of a broad set of selective interventions at the expense of a comprehensive primary health care (PHC) approach.
11. Historically, we know that significant health improvements firmly rooted in PHC only began to appear when the increasing political voice and self-organization of the growing urban masses finally made itself heard.** Why? Because the rich end up benefiting most when a major share of tax funding is allocated to larger, expensive, urban-based hospitals rather than to PHC services both in urban and in rural areas.
**: For long now, the People’s Health Movement has been saying that health is a political, a HR, as well as a technical subject. It has, therefore, been calling on WHO to accept the responsibility of engaging in the politics of health, as well as advising on technical issues.
12. A strong, organized demand for government responsiveness and accountability to social and HR needs is thus crucial to secure pro-PHC public policies. A process of social mobilization involving broad sectors of civil society, which may take different forms in different contexts, is essential to achieve and sustain such a political will for a genuine PHC.
Repercussions on health care financing
13. Today, the potential for agreement among rich countries in pushing disease-centered health outcomes is much greater than the potential for them agreeing to help finance health-for-all strategies and more equitable income distribution strategies. It is clearly ideology that is getting in the way of finding progressive solutions.
14. We already know that user fees at the point of service prioritize efficiency over equity. As the evidence demonstrates, in practice, user fees for health services are both inefficient, regressive and against the grain of the human right to health concept. While the academic argument on this has been won, the practical implementation of universal access, tax-based-free-care-at-the-point-of-use is proving to be ¬the barrier we all should get involved-in as a matter of priority.**** What matters most in health care financing today is reaching universal coverage in as many countries as possible. For this, the size of the pool remains the key factor in any insurance scheme. The argument goes like this: The greater the risks***** and the larger the resources pooled together, the wider the coverage, the greater the financial protection, and the greater the chances of achieving financial sustainability.
****: Is community-based health insurance an alternative? Contended issue. Why? Because the poorer are much less likely to join a scheme like this if premia are not subsidized. Hence community-based health insurance definitely requires support from the central government. Varied mechanisms to ensure sustainability of such schemes have been attempted in numerous countries, but have often conflicted with equity concerns, i.e., they stubbornly exclude high-risk individuals from membership, this affecting the sickest and the most vulnerable members of the population. Otherwise, increasing premium levels will discourage the poor from joining. Otherwise, placing limitations on benefit packages may enable better financial sustainability, but will limit the attractiveness of the scheme (Bennett et al. 2004). Overall, community-based health insurance offers only a marginal improvement over user fees. It is no panacea.
*****: Note that traditional public health and actuarial research uses a risk-factor approach; such an approach fails to reveal multi-causal mechanisms and to reveal the root causes of health inequities.
15. At the end of the day, it is the relationship between the state and society (their social contract) that will determine the feasibility of implementing a fully tax-based system. Tax compliance is based on ‘an understanding’ between the government and its people. Since most taxes are collected where there is primarily voluntary compliance, the collection of taxes requires substantial coercive power and for the state to be legitimate. No country, no matter how rich, has sufficient resources for penalizing all those who do not respect the tax laws.
16. The level of social cohesion across socio-economic groups is also an important constraint to the successful implementation of tax-based health care financing schemes, particularly in countries with high levels of income inequality where the rich may feel that they pay too much to subsidize others. Taxation and tax reform are central to state building.
17.If the above is somehow resolved, the biggest concern that still remains is how to extend coverage beyond the formal sector and without discriminations of any kind. (We are aware of the persistent failure to tax the informal sector… but beware: Informal does not mean poor).
Repercussions on maternal mortality
18. Human rights treaties and conventions do not include an explicit right to women’s health. But failure to address the preventable causes of maternal death is a violation of women’s human rights, for which states can be held accountable. (HR Council resolution in 2010)
19. It is important to highlight the fact that social injustices contribute to avoidable maternal deaths. As you know already, once an issue is recognized as a human right, there is a legal obligation to take steps that are deliberate, concrete and targeted towards the realization of the right. This, then. underlines the importance of the paradigm shift needed in local heath systems policies.
20. Furthermore, the life-cycle approach preferred by several new-age maternal health rights proponents continues to identify reproduction as the criterion for defining the stages of life. This strategy leads to simply further medicalizing reproduction and neglecting the rights of women with little attention being paid to local needs and social realities.
21. In short, maternal health needs need to be addressed within the larger framework of collapsing health systems. It is thus a fallacy to consider the number of institutional deliveries a proxy for better maternal health care.
Claudio Schuftan, Ho Chi Minh City
cschuftan@phmovement.org