Human rights: Food for a non-charitable thought ‘Access to health’
Human Rights Reader 498
-Coverage is not the same as access!
1. Considering health as an-end-for-economic-development represents a purely utilitarian approach to health. (Committee on Macroeconomics, WHO) Instead, health-rightly-considered-as-a-human-right (HR) mobilizes social forces to address its social determinants so as to effect needed health outcomes.*
*: It is the force of claim holders that can and must influence the social determinants (such as ecosystem degradation, income inequality, violence, globalization, corruption, migration, militarism, poverty, racism, social isolation and gender discrimination) to eventually shape fair health outcomes.
Claim holders organized and mobilized as a key social force have to address what is included in the acronym PEARLS+ that stands for:
• P for Politics, i.e., how do political priorities and systems of power affect social patterns that either enhance the quality of life or marginalize segments of the population?
• E for Economics, i.e., what levels of domestic and international inequality exist and how do economic policies address or further contribute to these inequalities?
• E also for Environment, i.e., do policies exist to protect against environmental determinants (including, for example, water, air, and vectors, plus exposure to hazardous materials or conditions), and, if so, how are they enforced?
• and E also for Ethics, i.e., what ethical and HR tenets guide medical and public health practice and how does their use advance or hinder equality across social boundaries?
• A for Arms, i.e., how much money is allocated to military expenditures relative to funds directed to social services and what are the implications of that distribution?
• R for Religion, i.e., what is the influence of religion on social attitudes and how do religious convictions guide medical practices, health beliefs, and individual behaviors?
• L for Life circumstances, i.e., how do fear, depression, anxiety, and oppression influence individual and collective behaviors and how have they been shaped by both local and global historical experiences?
• S for Social roles, i.e., what are the common rules of interpersonal interaction and how do variations in gender, ethnicity, geography, social status, and education affect them?
• S also for Social structures, i.e., what social institutions inhibit or enhance equity and equality and how? and
• + for Other forces, i.e., given differences in culture and context, what other forces, including interpersonal interactions, have a role in promoting and perpetuating adverse social determinants of health?
PEARLs+ insists that disparities in health outcomes are systemic and socially produced. Therefore, focusing on the social determinants of health and the social forces that influence them is thus crucial to the work of improving health outcomes of people worldwide. What is needed is to help health care practitioners and educators investigate and describe to then organize to proactively address the social forces that affect the social determinants of health and consequently affect health outcomes. (William Ventres, Jay D. Kravitz and Shafik Dharamsi) https://journals.lww.com/academicmedicine/FullText/2018/01000/PEARLS____Connecting_Societal_Forces,_Social.36.aspx#pdf-link
The right to health has to be taken-up-by rather than bestowed-on or given-to the people top-down or, worse, as charity
Pity is easy, but caring is difficult. Charity, even if sometimes commendable, is not a right and lasts only as long as the giver wants it to last or funding is available.
2. The fallacy that needs to be uprooted is that public health programs ‘implicitly’ address fundamental issues of human rights. In the HR framework nothing is left implicit. Without retooling to an explicit HR focus, such claims remain but hot air.
3. The difference is between a) just delivering/receiving the usual services, and b) making it clear to claim holders that they are legally entitled to specific services and can go somewhere concrete to complain if they do not receive what is due them.
And then there are attempts at health sector reform
4. Health sector reform initiatives are more often than not ideologically and politically determined and their ultimate objectives stay opaque or ill-defined. They are rarely based on a potential impact assessment that is adjusted to the current health situation and rarely provide a precise description of how a desired future situation is to come about in terms of greater equality in the distribution of health services from promotional to rehabilitative. This frequently makes it difficult for researchers to specify research questions and to select appropriate indicators when attempting to evaluate the effects of a particular reform element. (Erick Blas)
5. We know that poverty is the single most important determinant of preventable ill-health, malnutrition and deaths. But health is very far from being the single most important determinant of poverty! Poor health exacerbates existing poverty. Poor health you get, in part, from poor health services. (Alison Katz) Health sector reforms must (and seldom do) take this into consideration.
And then there is privatization
6. The (dreaded) privatization of public services has negatively impacted on the social contract that exists between the state and its citizens. The new private provision of basic services transforms this contract into a private contract that degrades the citizens who become mere customers. Citizens have legitimate rights to access social services they participate in designing.** Governments privatize them and ask questions later. (D+C, Apr 2003, Vol.30 Nr. 4 p. 137)
**: A ‘deliberative democracy’ in public health proposes that both claim holders and duty bearers set on applying the right to health are to meet ongoingly to deliberate about the different challenges that society faces on related issues, because only thus will claim holders be able to feel they are protagonists of the measures taken on health matters applied to the concrete prevailing political context. (Luis F. Gomez)
And then there is targeting
-Target not those rendered poor, but the process that day-in-day-out impoverishes them.
-A population-of-interest should be self-defining and not ‘targeted’ in a top-down process!
7. Many currently proposed approaches to resolve health problems, including the ones from the World Bank, focus on targeting. It is a fallacy to propose targeting as an alternative to comprehensive PHC as originally conceived in Alma Ata. Individual targeting is equivalent to the discredited ‘selective PHC approach’ dating from the 1980s. “Go for the worse cases, fix them and improve the statistics”. But where are the sustainable changes to avoid the recurrence of the same problems and mistakes to be seen? Targeting keeps a semblance of equity and equality. Targeting can and does stigmatize those rendered poor creating 2nd class citizens that can be manipulated. Individual targeting is not a substitute for a more redistributive public policy. Geographic targeting has more potential –if the area(s) chosen is(are) historically rendered poor. Starting with targeting interventions as the central thrust to achieve equality is the wrong approach; it pursues what is rather a ‘mirage of equality’. It tacitly blames those rendered most vulnerable for being where they are and tends them a crumb of bread as a rescuing hand.
And then there are PPPs and multi-stakeholder platforms
-Medical labels have been affixed to problems that are essentially social and political.
8. The Global Fund, public private partnerships and the neoliberal capture of WHO: ‘Health for All’ (HfA), launched by WHO in 1978 was a revolutionary social justice project that identified poverty and inequality, within and between nations, as the major determinants of avoidable and premature illness and death worldwide. It was deeply threatening to rich member states and was rapidly dismantled. Since then, WHO has been progressively diverted from its public health mandate by public private partnerships (PPPs), of which the Global Fund is the largest. PPPs are central to the neoliberal capture and to the ‘privatization’ of WHO. (Not far behind ranks the SUN initiative in the area of nutrition). TNCs seek new spheres for profit making and the health sector is worth trillions of dollars as the World Economic Forum constantly reminds them. Addressing root causes of health problems (i.e., miserable living conditions) is not profitable and is ignored in favor of technological interventions that are cosmetic and unsustainable.
9. PPPs and multi-stakeholder platforms allow private interests to set public health agendas that sacrifice broad public health goals of prevention of disease and promotion of health. Basically, WHO and other UN agencies are partnering with the private sector, because public sector budgets (member states contributions) have been slashed since the early 1990s. The Global Fund reports successes, yes, but progress in the right to health has been shamefully slow (in parallel with grotesque increases in inequality, nationally and internationally). No country is on target to meet the health related SDGs. Far more progress would have been achieved through HfA based on economic justice –not international aid. WHO still struggles for a genuine revival of HfA, but powerful member states representing their TNCs continue to weaken the people’s international health authority. WHO must be supported against this influx in the interest of democratic global health governance. (A. Katz)
And then there is the scare of NCDs
10. In the case of NCDs, face it: Little or nothing of consequence can be expected from the private sector, from UN agencies, from philanthropies****, from INGOs and from traditional donors.*** The challenge is in the public interest civil society organizations (PICSOs) and social movements court –and the People’s Health Movement is in this struggle. (www.phmovement.org)
***: Stop talking philanthropy, start talking organizations-that-dodge-taxes-and-enforceable-regulation. (Rutger Bregman)
****: We know from the social sciences that institutions tend to resist change. Every established social system is biased and resists reform.
11. As no surprise to you comes the fact that the more diseases cross class lines, the more investments they gather in their eradication (this has been called class-centered epidemiological profiles/ing).
12. Perhaps starting with NCDs, let us move the political economy of this justified scare from an unconventional spot in the political discourse to a central and essential spot in global health when addressing NCDs. (Michael Reich) Take, for example, the issue of health and nutrition education. As currently implemented, it is not an exaggeration to say that they perpetuate the capitalist system (a system that is ‘tatuated in us’) as they cover messages that stay well within a health system that separately caters for those rendered rich and for those rendered poor. (Maria Angelica Illanes) Nothing is covered about the social determination of health and nutrition…
Claudio Schuftan, Ho Chi Minh City
Your comments are welcome at schuftan@gmail.com
All Readers up to 490+ are available at www.claudioschuftan.com
Postscript/Marginalia
-Good health is the slowest possible rate at which one can die.
-That men would die was a matter of necessity; which men would die, though, was a matter of circumstance. (Joseph Heller, Catch 22)