-Of all the forms of inequality, injustice in health care is the most shocking and inhumane. (Martin Luther King)
-Health is not a matter of merely personal interest, but a universal concern for which we all share some responsibility. (Dalai Lama)
-When the right to health is debated in national elections, we know this is an issue whose time has come. (Mary Robinson and Andrew Clapham)
The ultimate purpose of health systems is the health of the population; it cannot be anything other…and this we have to repeat to ourselves every day and have to dream it every night (Asa Cristina Laurell)
1. To start with, let’s be clear: The intersection of health and human rights should take central stage when we seek a commitment for universal health coverage (UHC).
2. You all know that inequality has grown the world over and that the economic burden to access to health care continues to be important, with affordability being the key determinant to access health care.
3. If one pursues to satisfy the health needs of the whole population, universal health systems conceived as the provision of universal (though restricted) health coverage, as is now being pursued by many international agencies, actually have many disadvantages over the tax-financed single-payer option of a public health delivery system with free, universal access financed through the state. The public option is simply the fairest and the cheapest; it covers everybody, does not have to generate profits and has low administrative costs.
4. Let me explain: The calls we now often hear for Universal Health Coverage are mostly very vague. Calls for universal coverage are confused with calls for universal access. The former, often part of an insurance scheme, may not give access to all services so that we cannot speak of universal access.
5. In HR work, though, we are not looking for access to an insurance system that allows access to a restricted number of services. What we are looking for is a public health system with population coverage to all services according to need.* (A. C. Laurell) It is even more: The realization of the human right to health (RTH) further relies on the realization of other human rights (among other, life, food, housing, work, education, non discrimination, participation and freedom of association).
*: Classically, the RTH insists on four deliverables, namely, Availability, Access, Acceptability and Quality of services (AAAQ)
Health is a common good. We reject it having become an ‘industry of disease’
-The fragmentation of global health by disease runs against human rights (HR) principles. Yet almost everybody these days, including donors, speaks of the human right to health. Why? Because nobody trying a reform of the health sector dares to go against what are now widely shared values. But beware of wolves clothed in sheepskin!
-In current official development assistance (ODA) parlance, human rights and moral arguments for global health assistance are indeed present in the discourse, but do not appear too much in practice; they are part of the traditional ‘low politics’ of ODA. Most states, even when committed to health as a foreign aid goal, still make decisions primarily on the basis of the ‘high politics’ of national security and economic interests. (Ron Labonte)
6. Health insurance, as we know it, has multiple administrators and providers that focus on personal (mostly disease-centered, curative) services. This makes the possibility to act on the social and economic determinants of health almost impossible. The main drawback is that the government is an external agent where insurance companies operate autonomously. (A. C. Laurell)
7. To make them financially viable, universal health insurance systems only give access (they facetiously call it ‘the right’) to a limited package of services. In so doing, they do not intend to open access to all needed services, i.e., universal health access, but rather assuring that everybody has an insurance even if the same does not guarantee access to comprehensive services (from primary to tertiary). Such an insurance model converts the administration of its funds and the purchase of health services into a (not so) new field for the for-profit private sector that calls this institutional arrangement ‘democratic’(!) and calls the public health care delivery model ‘bureaucratic’.*
*: The private sector insurance has indeed had a very high profitability margin and has strengthened its position vis-à-vis the public sector. The undeniable success of the private sector is to have become a buoyant business in the health sector. (A. C. Laurell)
8. We must, therefore, be alert to differentiate between ‘population coverage’ (which may be a health insurance coverage just making a package of minimum services available**) and ‘services coverage’ (which means full timely access to all health services required).
**: These packages are often designed around cost-benefit analyses that are very constraining and almost invariably require a co-payment.
9. If we talk about equality (a key HR concern) we will say that in public health systems, equality is high although many obstacles will have to be removed to achieve a good planning and execution of programs –and we acknowledge this improvement in AAAQ does not happen automatically. In health insurance schemes, equality is elusive depending on the packages offered, their costs, their co-payments and members additional insurance needs. Actually, since these schemes do not cover everything, inequality is rife.
10. Bottom line here is that private health insurance schemes destroy the public health system; they are expensive and have high transactional costs; furthermore, they often receive public subsidies and have contributed to the budgetary crises that have led to a reduction in the public health services offered. (A. C. Laurell)
‘Paralysis in analysis’ as regards addressing the social determinants of health
11. After years of inaction, it has become clear that the social determinants of health (SDH) are not so amenable to change by amending health programs as much as by political movements that aim at removing structural barriers that ultimately redress poverty and change class relations.
12. The current discourse is stuck with targeting lifestyles, olympically ignoring the social, economic and political determinants of health. A patent example is the new approach arrived-at in New York to address the non-communicable diseases epidemic.
13. It needs to be repeated over and over: An exclusive focus on health and on the individual omits so much that we must now reconsider its use and usefulness.
14. A narrowly applied epidemiology identifies ‘risk behaviors’ of individuals in isolation from their social context; it thus distorts our understanding of the facts and, consequently, the decisions we make. Such an epidemiology imprisons health in a biomedical straitjacket that does violence to its potential as a tool for the right moral and political action.
Claudio Schuftan, Ho Chi Minh City
cschuftan@phmovement.org