Fair priority setting is essential to the realization of the right to health.
1. Achieving justice in health-care priority setting involves applying a range of substantive ethical and ideological principles that extend beyond primarily utilitarian calculations of which policies maximize health care costs. Among them, equality of access to health care and health services, as well as equality of results are always to be emphasized.
2. Inappropriate health resources allocation can and does lead to discrimination that may not always be overt. (General Comment 14). Policy maker committees are to be brought together to, on moral and legal grounds, respond to such discriminations, i.e., securing equal consideration for all individuals. (The right to health framework clearly explains why these committees are to be called in the first place!). Why? Because the right to health does provide the framework for dealing with issues of discrimination, exclusion and the power asymmetries at their base, decisively establishing the normative aspects of the moral principles to be the center piece in priority setting.
3. Importantly,
(a) The debate from the human rights perspective forces attention on issues of equality.
(b) The human rights framework offers the important key tools and mechanism for citizens to demand the needed additional resources.
(c) Interpreted correctly, the realization of the right to health is to be an integral consideration in priority setting by identifying concrete and distinct priorities for changes in the health-care system. (Note that priority setting is neither about a utilitarian drive to maximize health benefits across the population, nor is the right to health only about securing every individual’s access to health care totally regardless of cost).
4. Taking all this into consideration, ad-hoc panels are to be set up to deal with the wider questions of allocative efficiency in the realm of fairness –not forgetting the needed actions that address the social, economic, and political determination of health. Such bodies must be accountable to their populations, the executive, the legislative and the judiciary branches of government. Finance ministers are then to reappraise their budgets, considering the state’s obligations under this right. (Since the right to health is binding, resources have to be made available whether through taxation or other means). When the status-quo fails to uphold the right to health, changes pursued by claim holders, including judicial remedies, are needed.
The capitalist ideology manifests itself in the ideology of health and health institutions (David Sorkin)
5. Bringing-in the private sector has accentuated the silo mentality in the provision of health care services in the name of its ‘purported-role-whose-time-has-come’ –overlooking the fact that the latter is squarely centered around the profit maximization principle.* (Sandra Vermuyten)
*: The struggle does not end with eliminating private financing in the sector. Efforts must be made to ensure that public financing indeed serves to build more democratic, participatory and accountable systems that serve the needs of communities. Community engagement is a vital component of this process and governments must ensure that mechanisms are set up to effectively involve claim holders in decision-making. (Meera Karunananthan)
6. The free market ideology influences all spheres of life in neoliberal economies, including how health systems are organized and why health is considered a consumer good as opposed to being a right or a vehicle for securing a life of dignity.** Without effective regulation of private and of public health care supply, the market delivers the illusion of freedom –the freedom of the consumer– while in reality creating a situation of exclusion and of services degradation. (Alicia Yamin and P. Bergallo)
**: The so-called ‘health system’ is in fact a ‘disease system’ where the focus is on the market and the commodification of health care and where, as a result, the system promotes illness …and kills; it is controlled by a handful of corporations –many of them the same ones making agro-toxic products as is the case of Bayer. (Declaration of Rosario, June 16, 2017, Encounter Intercontinental Mother Earth, One Health, 4th International Congress on Socio-environmental Health)
7. Furthermore, the deep linkages between neoliberalism and the plutocrats that cynically condemn single payer (tax funded) health systems are also related to other ideological and biomedical biases they hold that, for instance, condemn women’s control over their own bodies. Actually, it is women who invariably experience the greatest marginalizing effects of neoliberalism, as well as of the extreme religious ideologies. Women require the realization of the full spectrum of human rights, including benefits to education, employment, and equal protection in addition to access to health care (the same is true for the LGBT community). (A. Yamin and P. Bergallo)
8. Do you agree with this set of iron laws?
• The capitalist ideology manifests itself in the ideology of health and health institutions.
• Medicine legitimizes the capitalist order (a medicine that sometimes produces more comfort than health…).
• Epidemiological profiles are often class-centered and support the legitimacy of the prevailing economic model. External top-down pressures on epidemiologists are very significant.
• Academic qualifications overshadow compassion and a desire to serve the people.
• Health systems form part of the totality of social and productive relationships and thus mirror the society’s class structure.
• Disease patterns and health care cannot be dissociated from social, economic and political powers.
• Different modes of production are associated with different patterns of disease.
• Different social classes are differentially affected by occupational diseases, accident rates, and diseases of poverty.
• State responses to health needs reflect emerging or existing class forces. Race and tribe may appear as important as class and gender in determining access to health care and other resources. Yet in neither case can these be dissociated from class.
• Tribe and race are not natural categories, but are social and ideological constructs. What needs to be clarified in each case is the precise relationship of ethnic origin with class divisions.
• Human problems arising from race relations are social and not biological in origin.
• Allocation of health care resources is a powerful legitimating tool used by the rulers and deeply affects the ruled. It is a recipe for domination and at the same time a means of reconciling obligation, power and beneficence.
• State and class relations are predictors of the nature of health care allocation.
9. For all these bulleted reasons, further gains in outcomes resulting from targeted, vertical health interventions has been declining. (David Sorkin)
In most countries, the health sector is perhaps the sector that has least to do with health
10. It is the wider political and economic forces that generate the direct causes of preventable ill-health, preventable malnutrition and preventable deaths. Health is at best a contributor. Although medical bureaucracies are not necessarily generators of capitalist dependencies, they are their administrators choosing to use technological knowledge and technical education and training as reinforcers of capitalist hierarchies. Health can and does act as an entry point for human rights activists’ initiatives, but they need to be aware that national development priorities are often at odds with improving health. This is where the role of health education comes in, yes, but as a conscientization tool, not only to teach health behaviors. (Vicente Navarro) The right to health and the social and political determination of health cannot be omitted in ongoing and upcoming human rights learning activities for claim holders.
Beware: Health care priorities funded by the World Bank are expected to contribute to economic development, not to the inalienable people’s right to health
11. It is clear that countries rendered poor are experiencing new forms of subjugation to the accumulation of capital that are explicitly hazardous to public health. The attempt to prove the feasibility of solving the public health problems of the people rendered poor using solutions within the framework of capitalist/technocratic/biomedical/vertical alternatives is clearly ideological. Seen from that ideological perspective, health care interventions are used in an attempt to counteract the logic of public health imperatives. This means that, under capitalism, disease may well be socially produced, but the responsibility for health is assigned to the individual(s). The requirements of the accumulation of capital are masked by the technocratic mystification of alternative solutions. But health care per-se cannot be liberating except possibly from disease. Health care may become a praxis of liberation only as an integral part of a political liberation program since health care priorities express class relations and distribution of economic and political power. (Najwa Makhoul)
12. After 40 years, the primary health care (PHC) experience in countries rendered poor has so far been dismal showing that health and politics are interlocked.*** The social and political roots of ill-health and malnutrition have thus to be taught to the newer generations –this, because the democratization of the health sector is ultimately inseparable from the democratization of all institutions of society.
***: Ultimately, health services can be community supportive (encourage responsibility, initiative, self reliance) or community oppressive (paternalistic, dependency creating, initiative destroying).
13. Countless central global bureaucratic health planning and programming efforts have attempted to influence countries’ decisions concerning their strategies addressing health. It is only when countries themselves muster their political will and take in their own hand the preparations for their national strategies that a sound and realistic basis for developing bottom-up regional and global strategies will emerge. (Halfdan Mahler)
The contributions of human rights to universal health coverage
(Andrew Chapman, Health and Human Rights 18(2) December 2016
https://tinyurl.com/ldpu9bz)
14. Recently, there has been a growing push for countries to achieve universal health coverage (UHC) in order to strengthen health systems and improve health equity and access to health services. Importantly, not all potential paths to a universal health system are consistent with human rights (HR) requirements. Simply expanding health coverage, especially if it continues to exclude communities rendered poor and vulnerable, is not sufficient from a HR perspective. There are requirements that a HR approach to UHC imposes. These include:
• locating UHC within the context of a national effort to provide equitable access to the social determinants of health;
• making access to essential health services and public health protection legal entitlements that include redress measures for failures to provide these benefits;
• paying explicit attention to equality in the design of the universal health system including in health financing;
• incorporating opportunities for consultation-with and the participation-of the population in the design of the path to UHC and the determination of benefits packages.
15. The process for pursuing the progressive realization of UHC is to first expand coverage for high-priority services to everyone with special efforts to ensure that disadvantaged groups are reached. The goal of achieving UHC can generally be realized only in stages, through a long process of gradual and progressive realization, given the limitations in resources availability and administrative capacity –and this imposes difficult trade-offs along the way.
16. As they progress towards the achievement of UHC, policy makers face two ethical imperatives: to set national spending priorities fairly and efficiently, and to safeguard the right to health. Policy makers cannot avoid asking themselves over and over: If illness is universal, why is health care not? (Raj Panjabi)
Claudio Schuftan, Ho Chi Minh City
schuftan@gmail.com
www.claudioschuftan.com