Over 2.300 years ago, the Greek philosopher Aristotle said that “if we believe that men have any personal rights at all as human beings, they have an absolute right to such measure of good health as society, and society alone, is able to give them.”
- We used to say that health is too important to leave it to the doctors. Then some said it was too important to leave it to the state. Now, we forcefully say it is so important that we must leave it to, nothing less than social movements. (Asa CristinaLaurell) Why? Because effective action to address the social determination of health (SDH) and the concomitant health inequalities and violations of the right to health* will have to primarily come from civil society actions and pressures. Think of the history of your country…does this apply?
*: According to WHO, the right to health is not the same as theright to be healthy. A common misconception is that the State has to guarantee good health for everybody. However, good health is influenced by several factors that are outside the direct control of States –although human rights-based health legislation is indeed a priority. An individual’s right to health cannot be realized without realizing other rights, the violations of which are at the root of poverty, such as the rights to work, to food, to housing and to education, and to the principle of non-discrimination. This is very much the result of the fact that ill-health is a symptom or an outcome of much broader and deeper problems in society. Therefore, health practitioners must have some knowledge about the key human rights, in particular the economic, social and cultural rights. This is required to carry out very ambitious and indeed needed Causality, Capacity and Pattern Analyses as required when applying the human rights framework. (UrbanJonsson)
Focusing on the ‘Health Have-Nots’(AnwarFazal)
- All the time, ministries of health tell us human rights activists “we may have formal differences of opinion with you but, substantially, we all have the same objective”. Nothing could be further from the truth. We simply come from different, or even opposed, schools or frameworks of thought. Those of us who defend the right to health go well beyond technical issues in health, i.e., for us, nobody should lack access to comprehensive health care because s/he cannot pay for the services or lives in more remote places. If we would agree on this, yes, anything else is amenable to negotiation –but being very clear that no existing norms and policies can ignore that the aim is for progressively attaining equality in health. For instance, the respective ministry cannot call universal health insurance a progressive-public-policy when, in reality, it does not offer the same coverage for everybody; it cannot call comprehensive insurance what, in reality, may reimburse for health care that is not comprehensive, but is rather based on different health care packages –different for different groups, only trimmed-down-ones for the health have-nots.
- The framework from which human rights activists come-from is based on reforming the health system based on three inseparable principles: Universality and Comprehensiveness of public health care and Solidarity (to each according to her/his needs and not her/his means). Only the application of these three principles can guarantee equality since they are the basis of all human rights (HR). Furthermore, in shaping equitable health systems, it has to be together-with-claim-holders that one decides and prioritizes the actions to be taken.** (AlexandroSaco)
**: Unfortunately health services have often become places of deprivation, inequality and exclusion. Therefore, it is claim holders that must demand a better position to respond to the challenges this brings about. In this context, it is important to recognize that the human right to health actually means the-right-to-command-the-whole-health-planning,- implementation-and-monitoring-process, i.e., establishing a democratic management of health care. The aim must be a people-centered, sustainable development in health. Health, within the economy, must be changed from being considered an engine of growth and productivity to fostering truly active HR agents of change.(UrbaJonsson)
- The above is not, as far as I know, what ministries are talking about in their plans for health system reform. It needs emphasizing that, for the most part, States are not channeling resources to claim holders that need those resources the most thus securing and guaranteeing the fact that all human beings are assigned the same rights. The public health sector can simply not (but is) deny(ing) services to somebody, because s/he is living in poverty and/or is marginalized. We are not talking about ministries having to have social programs; we are talking about them having to have human rights-based programs. (Those who can afford it are free to pay for private services, but that does not deny their right to use the public services). You can thus see the differences are not formal only. We do not deny that there is plenty room for ministries to implement operational, organizational and administrative measures to improve services, but these are not in the direction of the human right to health, because they ignore the three principles above. They actually have, for long, been responsible of a further denial of universal health care coverage, have offered minimum basic packages for people rendered poor and have ignored any notion of solidarity.(A. Saco)
| The road to fulfill the right to health for all the health have-nots implies the setting up, the strengthening and the development of Tax-Based-Universal-Public-Health-Systems. This position contravenes the campaign currently being launched by international financial institutions, UN agencies and by neoliberal donor governments to address the under-discussion concept of Universal Health Coverage which they base on the widening of different insurance schemes, on limited basic health services packages for the people rendered poor and on the promotion of private investment in the health sector. But health cannot only be conceived as the provision of curative services. We know that health implies looking after a whole set of interdependent HR since health is, among other, ultimately determined by the de-facto access to an environment free of toxics, to healthy production models, as well as to decent housing and quality education, to clean water and sanitation, to land redistribution…Along the same lines, the recognition of the right of the people and of communities to a free and informed consultation and participation in the formulation of health policies has been a clear unfolding historic achievement.
We are keenly aware of the negative effects the extractivist model of natural resources and the predatory behavior of the agro/food/beverage industry both have on health and on the livelihood of communities –not forgetting the ecosystem. Numerous studies have rigorously demonstrated the fact that health is socially and environmentally determined. Therefore, from the social medicine point of view, it is alarming that much of the current discussions have been focused on the right to health care of a minority disregarding what literally is the HR to life of vast majorities. (We are talking about a class-based differential risk exposure to premature preventable deaths). Related to this, we consider that the debate on tax and fiscal reforms is crucial (and realistic) so as to come-up i) with redistribution of wealth policies (= disparity reduction), ii) with the universalization of HR, iii) with citizens participation and iv) with ‘healthy’ public health policies, as well as v) with seeking alternative production models that are not ecologically destructive and are equitable. (AsociacionLatinoamericana de Medicina Social, ALAMES) |
A birds-eye view of the conditions necessary for health systems to be equitable and universal
The right to health is far more than the individual liberty to access health services and resources: it is a right to change ourselves by changing the health system. Moreover, it is a collective rather than an individual right since this transformation inevitably depends upon the collective exercise of power specifically acquired to reshape the processes of how health services are delivered. (Henri Lefebvre)
- Universal Health Coverage (UHC), even if considered a HR in the ongoing debates, does not per-se address the actual determinants of health outcomes (which include the usual indicators of the many deprivations of marginalized groups prominently including household poverty). Therefore, UHC must also, among other, include affordable access to medicines and an effective and performing domestic health care system.*** (M. Montes)
***: Sir Michael Marmot introduced the concept of ‘Proportionate Universalism’ in the UHC debate. By it, he meant that actions to achieve UHC must be universal, and of a scale and intensity that is proportionate to the level of disadvantages in health in different countries. ‘Benchmarking tables and figures’ have been used in this context to compare a country’s progress in health with that of its peers, called ‘comparator countries’.
- Four key ingredients have been said by some to be necessary for the successful financing of UHC: i) removal of direct payments and other financial barriers; ii) compulsory pre-payment; iii) large risk pools; and iv) financing from general revenues to cover the uncovered. But conventional insurance schemes –whether private, community-based or European-style social health insurance– come up short when measured against these criteria. Since UHC is about access to quality care for everyone regardless of ability to pay, governments must move away from relying on employment-based and contributory insurance models. Instead, health care must become a right of citizenship (or actually of residency so as to include migrants), financed in large part through general government revenues. Equality must be built into the system from the beginning, rather than starting with those easiest to reach in the formal sector. (Oxfam)
A quick peek into the non-communicable diseases debate
- The case of non-communicable diseases (NCDs) is an example of how profitable solutions are applied to potentially profitable problems. In this regard, it is striking that problems that should be addressed through binding legislation are being timidly addressed as requiring industry ‘cooperation’ or ‘voluntary’ codes of conduct. (Alison Katz)
- The 1993 WHO World Health Report (the ‘Sachs Report’) made health-as-an-input-to-increased-productivity a respectable concept. Since then, a myriad of documents promoting action on NCDs have gone and go even further: they alert the private sector to see health as a market opportunity. The ‘hard sell’ of actions to tackle NCDs overwhelmingly removes their social and economic determinants from the debate and focuses instead almost exclusively on risk factors relating to individual behavior, e.g.: “If you smoke you do so at your own risk” or “It is you who are responsible for your excess overweight”.**** This is the typical victim-blaming-approach of the neoliberal era taken to the extreme! (A. Katz)
****: Keep in mind: i) obesity is a normal response to an abnormal environment; and ii) tobacco, alcohol, sugar/transfats& fast-food big transnational corporations are to be seen as ‘vectors of disease’ that need national monitoring in the same way as other vectors. (R. Moodie)
- The structural root causes of disease and of poverty are of no interest to the rich and powerful. On the contrary, the highlighting of these causes represents a threat to the status-quo as they address extreme and growing inequalities which bring this privileged group so many rewards both in geopolitical and economic terms. It is time to question the use of the term ‘risk factors’ and indeed the whole concept of risk. The term tends to imply individual agency and responsibility, i.e., as if people had the ability to fully control their lives and their environment. It ignores the critical distinction between risks taken and the risks imposed by the different manipulations of the market place that result in the skewed corporate power relationships we all know about.***** The terms ‘contributing factors’ or ‘determinants’ are more neutral than ‘risk factors’ and allow the real causes to be identified and analyzed without prior assumptions (or subtle suggestions) about the individual or structural origin of the causes. (A. Katz)
*****: Risks taken align four or more individual risk factors (especially for NCDs), but do so aligningthem like in a Swiss cheese so that remedial arrowscannotreally pass.
Claudio Schuftan, Ho Chi Minh City