Dev. In Practice, Vol.89, No.5, Nov.1999.
CLAUDIO SCHUFTAN
schuftan@gmail.com
If the present trends continue, economic disparities between industrial and developing nations will move from inequitable to inhuman. (Gustave Speth, UNDP)
If globalization is to deserve its name, it has to include, not exclude -to integrate, not to marginalize. (R. Ricupero, UNCTAD)
Equity in health is an inseparable part of equity in society overall. The current structural adjustment-sponsored growth paths in developing countries, and the ongoing process of globalization of the world’s economy we are increasingly witnessing, are against such equity (both globally and locally). Globalization has been said to be a feast for the rich and a tragedy for the poor… Both the structural adjustment and globalization processes have been and are fostering a worrisome polarization in the direction opposite to greater equity. Consider the following:
– In 1990, the richest 20% of the world’s population had 60 times more income than the lowest quintile; in 1960 the same ratio was 30 times.
– The 30 richest countries in the world now account for 78% of the global GDP.
– In 70 developing countries, levels of income are lower today than those they attained in the 1960s.
– Today, 1.3 billion people survive on less than a dollar a day.
– Sixty percent of humanity lives on less than two dollars a day (USD 750/yr), with no prospects in sight for this to change for the better.
– 1.6 billion people are worse off today than they were 30 years ago. [As a point of reference, just think for a moment how much wealthier you are today than you were in 1960…].
– The current economic decline has lasted longer and is deeper than the Great Depression of the1930s.
In a contrasting way, and through the process of globalization:
– The prices of luxury goods (TVs, electronics, and even cars) have come down while bare essentials such as rice, pulses and edible oils, to name but a few, have leapfrogged beyond the reach of most.
– Globally, and in spite of all UN sponsored development programs, from 1960 to 1970 the same poorest 20% of the world’s population only received 2.3% of the global income; in 1990, this proportion went down to 1.3% to about half of where it was 2 decades earlier. (1993 Human Development Report, UNDP).
– Chances are that, after the Asian crisis, this situation has worsened further.
– Adding to this same scenario are the facts that transnational corporations control 70% of world trade, and that international prices clearly reflect neither their social (and health) costs nor their environmental costs. (The latter should come as no surprise since Capitalism tends to favor rather short-term maximization of returns tactics).
On the other hand, keep in mind that serious health problems of poor people are not only the result of a lack of clean water, a decent house, sanitation and basic services (as linked to their socioeconomic status).
They also result from despair, anger, fear, worry about debts, worry about job/food/housing insecurity, and feelings of failure and social alienation. In short, chronic stress arising from social exclusion is as damaging to health as a meager income and poor access to services.
[Health, in reality, is not a measurable “state”. It has been suggested that “a modus vivendi enabling imperfect human beings to achieve a rewarding and not too painful existence while they cope with an imperfect world”. This definition sees health more in the societal context so that health can be understood more as being closely related to development and empowerment issues. Health, development and empowerment are linked to each other inseparably, with empowerment here representing a state of ‘understanding that one has power’ -and the broader that power base, the more sustainable health will be. (Dhital, S., 1995)]
Going back to basics, an equitable system is understood here as one that allows the lowest income sectors have access to an acceptable level of basic goods and services (health most prominently among them). Equity in health thus means somehow decreasing the differences in access to and utilization of all health services.
Globalization is understood here as the process of growing concentration and expansion of economic power in the hands of corporations and financial speculators -mostly from the North- that are progressively entering national economies worldwide using the mechanisms of penetration afforded by an externally imposed international free market ideology. Globalization leads to inequities in a number of ways, some of them explored here; if looked at with an eye for equity, it can also offer some limited opportunities.
Some health planners have argued it is a lack of a common language on health equity that has impeded equity-enhancing actions to be launched up to now both in the North and in the South. But a lack of definition of the social realm of (in)equity and a lack of appropriate indicators to measure this inequity are hardly the cause for this inaction; the latter two are more academic matters. Instead, inaction is explained by much more pragmatic issues, most of them rooted in overall power politics and a fair dose of procrastination.
One needs to keep this in mind, to avoid the risk of intellectualizing the equity issue.
Therefore, power politics can simply not be ignored in health. As activists in this field, we cannot look the other way; we have to deal with politics in some way or another.
Unfortunately, governments and state powers and actions are overwhelmingly disempowering. How can one then hope that such a machinery geared at disempowering the people can be committed to an empowering concept -let alone praxis- of Primary Health Care?
The World Bank and the IMF do not do much better when heavy-handedly negotiating terms with developing countries’ governments. They push for a greater role for market forces in the production and distribution of health care services. For them, the solution is to commercialize, commoditize and privatize health, even if at the cost of massive layoffs. Because people are already paying for health care, they assume people are willing to pay. But, even if true, willingness does not mean ability. (!)
In the real world, market forces, at the center of structural adjustment and the globalization process, have failed (and are failing) to deliver minimum acceptable health care services; as a result, continued government intervention has become inevitable. But we know that government expenditures on health in developing countries have been shrinking and have become a small proportion of overall out of pocket expenditures for heath by the people. (Mind that, as per the World Bank, expenditures of USD 8/cap/yr are deemed necessary to meet acceptable standards in curative services alone; this is roughly double or more the amount of total per capita expenditures on health of many developing countries’ governments). Quite obviously, people are being asked to pay for a significant portion of their own care. But are they able to? How many are (increasingly) being left out?
In the fee for service system and in the privatization of health encouraged by the forces of globalization, equity is clearly being sacrificed in the name of a yet to be proven greater efficiency. (Never mind that the private sector has historically been less accountable to users than the public sector…).
This move away from equity is not acceptable to the author and many others. This because the strategy of providing health care on the basis of need is being replaced by one based on the basis of cost recovery.
(Note that the poor often end up subsidizing services given to the richer segments in society; with escalating budgets for tertiary care, and with ‘hi tech’ equipment and procedures being concentrated in urban areas, the poorest of the poor paying user fees end up paying to resolve a funding crisis actually created by the rich and their needs).
Moreover, working payment exemption mechanisms for the poor remain an elusive goal worldwide. Private health insurance schemes, on the other hand, tend to price-out the poor for the health care they need and inflict on the rich the tests and treatments they do not need.
Therefore, a new language and new tools narrowly directed at promoting equity in health (alone) will not by themselves address the critical problems of inequity (neither in health nor overall).
The will and commitment to go ahead with the needed changes rather come from a resolute will to foster equity in society. Health policy makers cannot any longer make decisions that conflict with the equity goal.
The choice is clearly a moral one and cannot be made by the medical establishment only. (!) This because conventional medical institutions most probably, in a way, are miniature mirrors of the state; they (have) contribute(d) to create the existing gap between health professionals and the rest of the population, a gap that is most obvious in the commercialization of the medical profession so encouraged by globalization. *
The international forces of globalization do not particularly favor such a resolute will from local elites to foster equity (including equity in health -other than the rightly discredited safety nets of Structural Adjustment Programs; safety nets are nothing but part of a strategy to manage poverty attenuating social unrest at a minimum cost).
In a way, through globalization, we are growing a new class of people -the cheated classes- who are being institutionally victimized by governments that no longer care much to interfere with the victimizers (the globalizing forces). It is sad to think that the poor -most of them truly kind and decent persons- are being consigned wholesale to the cheated class by the process of globalization. (Russel Baker, Washington Post)
Therefore, no matter how much this will be denied, the politics of equity will override all other (health) efforts to bring about Health for All. And -particularly because of globalization- it is not the politics of health inequities per se that needs to be tackled: it is the politics of (in)equity overall in each society.
Equity in health cannot be handled (or achieved) in isolation. Social inequities are invariably determined by political inequities. Keep in mind that equity is the (forgotten) central thrust in the Alma Ata Declaration…
On the other hand, rejecting all rhetoric, the bottom line is that sustainability in health reforms must be linked to equity…and thus to politics.
In an era of globalization that has to be taken as a fait accompli. Health planners and communities have no choice but to examine the social, political and ideological foundations and determinants of inequity (nationally and internationally) to, from there, develop a framework for action. More than ever before, the health sector is in need of an overt political strategy (and tactics) both at the theoretical and programmatic levels. The concealed costs of inaction are enormous; take just one example: the annual costs of workdays lost in developing countries due to water related diseases are estimated around USD 125 billion while the annual cost of supplying water and sanitation is said to be only 30 billion.
We need to be clear: Beyond lip service, not all in society have an ‘aversion’ to disparities in health.
Globalization cleverly involves local elites in the free market economy myth and this paradigm accepts a (temporary…?) deterioration in social conditions (health included) as a price worth paying in the name of a (supposed) future trickle down -the evidence of which remains elusive.
Let’s face it, globalization does not have a human face. It does lead to what it implies: the virtual colonization of the whole planet. The term is thus a euphemism for a process of domination. Power differentials are at its crux. It is a process one cannot wish away.
And who gains and who loses from it in the long run is the ultimate questions to ask, because the globalization of the world’s economy is leading to the globalization of poverty through the intensification of the systematic (although perhaps now more sophisticated) plunder of the neo-colonies. *
As everybody knows, markets reward those who either have substantial purchasing power, valuable commodities or services to sell. Poor people and nations have neither. Poor people and nations serve the market and not vice-versa.
For the poor, the only way to achieve a normally functioning and healthy body is to alleviate their poverty. *
Nevertheless, cynic defenders of globalization contend that those that speak of arresting the onward march of market forces wish to keep the poor from the benefits of the 21st century. (!?) But we cannot be fooled: there hardly is such a thing as ‘equity enhancing forces of globalization’. If necessary, researchers will have to prove this.
Globalization rather distorts and deforms people’s needs and wants; people are refashioned in the image of the global market whose dependents they become.
Globalization affords its proponents the opportunity to make people internalize a ‘universal’ culture and common sense, the one that fits advanced Capitalism; and this is a convenient pretext to conceal the ultimate interests of the dominant.
An ailing social structure -such as the one resulting from globalization- also dehumanizes the caregiver-patient relationship. *
Therefore, unless this structure is changed, the shift in the concept of health from the dehumanizing and the disempowering biomedical domain to a more humanizing, empowering domain cannot be translated into practice.
An important prerequisite for this shift in domain is the demystification of medical knowledge, for people themselves to get more confident in dealing with health and disease from the individual, to the household level and up.
In all honesty, as intellectuals, technicians and politicians, we ourselves have become submissive to the new globalization paradigm as well. The deceptions are so brilliantly woven that falling for them is deemed as both fashionable and progressive…
Where then can ‘resistors’ like many of us run to shelter ourselves from (and regroup to react to) globalization’s negative effects (starting with at least those on health)? *
There is an additional role here for health professionals to call on their fellow workers to oppose and resist the negative effects of globalization both on health and overall, even if the alternatives are not clearly defined yet. People who are conscious about the deleterious effect of globalization on health have to muster the inner strength, based on old and proven public health equity values, to renew their combativity.
The only way to contain globalization is through intelligent responses to it.
Therefore, as said, it is in the interest of health equity to counter the forces of globalization rather than looking for an accommodation to fit greater health equity into an inherently inequitable globalization paradigm. Otherwise, we all will remain part of the problem rather than the solution.
To counter globalization, we need to help bring about a disengagement of relevant aspects of local economies from the negative effects of the totalizing embrace of the world market.
All of us need to perceive -beyond any doubt- our common fate (and the fate of public health) under globalization. And we ought to act accordingly.
If globalization is the agenda for corporate control, localization is the countervailing citizen’s agenda for protecting people’s health, survival and livelihoods plus the environment. Localization in no way implies insularity; it is an antidote to globalization and to unrestrained greed (Vandana Shiva). *
Because of all this, a sizeable proportion of our present day challenge lies outside the health field. A multidisciplinary vision can help in this, but is not sufficient. A clear political view of where things are going is more important and such a view needs to provide all further guidance on this. In health, this means that a renewed commitment and resolve to foster empowering community-based activities will have to guide our actions. Pronouncements alone will not do; what counts are deeds.
Accordingly, NGOs should have a more prominent role in this process of localization, i.e., finding the ways in which they can help people to negotiate for themselves and help them develop the conditions whereby a greater social cohesion and social purpose are possible. Screening the NGOs that will embrace such a people-centered path will be a challenge.
More and more, health actions will have to support and be in tune with overall people’s empowerment movements around the globe. There is now talk of PETHAs: People’s Empowerment Through Health Actions (Dhital, S., 1995).
[Some have called for ‘giving globalization a human face’; among other calls, they have proposed getting at the heart of globalization, namely at the multi-billion dollar daily electronic international financial transfers and transactions; it is proposed to tax them (the much touted Tobin Tax). Finding large enough constituencies or coalitions willing to fight such a fight has proven difficult; plus the odds are colossal. But even if this laudable potentially millionaire initiative is feasible, could the proceeds of such a tax be directed to localization efforts? Would the powers that be let themselves be had twice, once by being taxed and then by allowing the proceeds to be invested in strengthening anti-globalization forces…? No matter what the odds, this attempt at ‘humanizing’ globalization is an avenue worth vigorously exploring further (although we would have to find a new, better name for it)].
Growth and equity need not be trade-offs, and development is not a zero sum game; we know these two facts. But boldly analyzing current trends in globalization-led growth (especially its effects on health) leaves us with little room for optimism. One thing has become abundantly clear: development does not happen simply by liberalizing the economy (nor does health, for that matter). As practiced now, the current brand of liberalization is morally unacceptable and economically inefficient.
Poorer countries are increasingly missing out on the promised benefits of globalization and liberalization, because they both proceed in a lopsided way, are primarily motivated by (exploitative) profit making, and have encouraged widespread corruption.
The time to switch paradigms and get involved is now. At this conjuncture, some soul searching is called for. The basic conflict to resolve is whether to cling to older convictions or to see through them, let go and adopt needed new approaches that can break the status-quo (or the deteriorating trends…).
Finally, a special area of concrete concern for us all in health (one that brings us closest perhaps to the direct threats of globalization) is looking into the role of transnational pharmaceutical houses in fostering yet more inequities in health in poor countries. More fellow researchers should embark in assessing and redressing this specific growing threat.
Reference:
Dhital, S. (1995), Health, Development, Empowerment and Politics. Link, Newsletter of the Asian Community Health Action Network (ACHAN), 13:2, pp. 28-30, Sept.
Acknowledgement:
*: I am indebted for some of the ideas here presented to the publication “Link”, the Newsletter of the Asian Community Health Action Network in Madras.
Claudio Schuftan
Saigon, Vietnam.