-Take care of the quality of life and the quantity will take care of itself. (Cicely Williams)
Start by thinking: Health is an animal condition, but most of our ill-health comes from two places: body and society (John Updike, The Centaur)
1. To further set the stage here, think: What does the following tell us? The high price society has to pay for health is indeed not the same as the high costs of health to society. This is not only an ethical and human rights (HR) brainteaser, but also a question that makes us ponder the difference between what is legal vs what is ethically legitimate for society to do.
2. We all know health benefits are maldistributed following the skewedness of income distribution. At a minimum, health services just tend to assure the reproduction of the labor force. By forgetting the macro restraints, we keep dreaming we can revert this situation leading to preventable ill-health and malnutrition and thus go for health for all –if only we do our technical work better and more efficiently…
3. Fifty years+ of targeting health interventions to those rendered poor* (i.e., pejoratively branding them) has not and will not lead to universal coverage –or, for that matter, to health for all. Not being facetious, over these 50 years, WHO has come with sensible advice; the World Bank has come with money for technical work. …Countries prefer the money…
*: We all know the social costs of productive activities are unequally distributed in society and the health benefits are biased against the groups of low income.
4. The fallacy that, therefore, needs to be combatted and uprooted is that public health programs implicitly address fundamental issues of HR. In the HR-based framework nothing is left implicit! Without retooling to an explicit HR focus many health programs and/or projects anywhere in the world, no matter how well funded, will remain but hot air.**
**: A good HR indicator is one that highlights and documents discrimination and violations, wouldn’t you agree? Therefore, only looking at epidemiological achievements from a HR perspective, does it become clear (not hot air) that we have to use indicators of non-coverage rather than of coverage. To take an example, we must report rates of non-vaccinated children. Doing so implies the need for further action to overcome their non-coverage (as a grave violation of those children’ right exposing them to a higher risk of dying) together with determining what claim holders ought to be loudly demanding to change the situation. [I know, immunization is part of a part of an answer to world health, but an important part!].
The haunting question is: When are we going to stop beating around the bush?
5. Those rendered poor keep getting sick from preventable diseases and we do not stop the cycle that leads-to and perpetuates poverty. Put another way, it is not about pro-poorness in health policy; it is about system correction –and not just about correcting implementation failures; it is about pro-healthness-within-poverty-reduction-policies! We are faced with a political/structural challenge in which elite technical decision makers are (rightfully) no longer trusted. (Wim Deceukelaire)
6. Decision-makers and academics do join movements, yes, but not necessarily those movements on the politics of the causes of preventable ill-health or, in other words, on the causes of the causes (or the politics of the politics…). (Posthumously David Sanders) The causes to tackle to address equality in health are not simply the same causes many medical and public health practitioners are addressing to solve clinical or strictly epidemiological problems; there is more to it, much more… (Fin Didrichsen)
Looking at equality in health from six different perspectives
-From early on, the dominant literature on public health from hegemonic sources disregarded the critical equality and HR perspectives on health as being central. [e.g., the 2001 Macroeconomics and Health WHO (Jeffrey Sachs) Report (https://apps.who.int/iris/handle/10665/42463), as well as Global Fund and Gates Foundation publications on health (https://www.theglobalfund.org/en/) (https://www.gatesfoundation.org/who-we-are/general-information/leadership/global-health)].
-The HR to health inspires and empowers!
7. So, now, we have to look at and ask:
• Ethics: The link between political pronouncements about health for the people and actual deeds; why is access not matched-by the utilization-of primary health care (PHC) services? Are we moving away from equality in health? If yes, why? How to revert the trend? What would be a feasible roadmap and what the role of applying the HR framework in it?
• Measurement: What existing indicators tell us that equality is decreasing? What additional indicators will help follow real trends? What is the role of sentinel surveillance of PHC? Greater inequalities result mostly in what type of health problems in the population?
• Social determinants: Do we have data by income? By ethnic or other vulnerable groups or minorities? Do we see differentials? If yes, why? (causes). How can we intervene to redress social determinants? Will knowing the causes result in the proper actions? If not why? What is the role of political parties in helping set guiding principles to revert the social determinants of growing inequalities?
• Gender: Is gender an import stratifier? Do we have data? If not, what to do? If yes, what to do? How is gender linked to health outcomes? Who needs to be involved to gain greater gender equality in health? Doing what?
• Healthcare financing: What are the negative effects of fee for service systems? How do they affect equality? (User fees in health are little more than an additional form of direct taxation affecting those rendered poor). Does willingness to pay reflect ability to pay? Are there alternative, viable pre-payment systems available? Which? How do they work? Why have essential drugs programs failed so far? How do low salaries of staff affect equality in health? Why has central funding for health decreased? Why is the MOH giving more priority to tertiary care? Is cross-subsidization of health possible? (from revenues generated in other sectors of the economy or from rich paying patients). Can we learn something from other countries?
• Globalization: How much or how little has globalization affected health equality? What is likely to happen in the next three years? What can we learn from other countries? What are warning signs to watch for? What is the role of international pharma houses in the country? What risks do they add to? How can we counter the disparity-generating forces of global market forces affecting health? Can we learn from other countries?
8. A couple of my iron laws are pertinent here
• Health care alone cannot bring about good health; the promotion of wider changes in society is also required. (You know that).
• Health care expenditures should be less unequal than the distribution of income in a society. (You know that too).
• The relative utilization of health resources and facilities by the different socioeconomic groups is an indicator of equality in the allocation of resources; so HR practitioners are to be concerned about matters of allocation rather than of distribution.
• Private health systems do not work; its supporters pontificate about it though attempting to give legitimacy to what is basically an unfair, unjust system that departs from the unproven fait-accompli that mixed public-private systems are needed so ‘those who can pay, pay’. Experience shows you end up with first and third class health care, the latter encompassing ‘minimum packages’ of different composition depending on the country…
• Often, those whose health attitudes and traditional approaches are most difficult to modify are not the villagers, but the professionals! (Antonio Ugalde)
• The ethnographic ignorance of health planners at global (or national level) about the health system(s) for minorities they are out to reform is supine.
• In our health work, we have to acknowledge claim holders and duty bearer roles together with recognizing their respective corresponding capacity gaps.
• What we need to be asking patients is: What does the denial or fulfillment of the right to health in your country mean in practice to you and your fellow citizens?
• Except for rare cases, critical social thought has no place in the education of health professionals.
What do you expect from the medical profession in the era of Universal Health Coverage?
-Clouds obscure the future of the medical profession –as imperfect as it is.
9. The commoditization of care undermines ethics and the right to health. Bureaucracy infiltrates practice. The doctors’ culture itself is made increasingly materialistic. Unsurprisingly, the physicians’ suicide rate is in the United States is the highest of all occupations, almost twice the national average, and higher than in the military (making decisions against one’s convictions partly explains it). But professional ethics can/ought to prevail over institutionally-set (insurance?) standards. For the sake of safeguarding professional ethics, doctors should act independently-of and prior-to the adoption of ad-hoc institutional policies. Unlike commercial management, public health care financing and publicly oriented management are compatible-with and favorable-to an ethical medical practice. Commercialized health care, especially in privatized systems, is antithetical to ethical and truly professional medical practice, anywhere along the spectrum from purely clinical service to fulltime public health work.
10. Patient-centered and HR-based care delivery in both clinical and public health practice must become the physicians’ moral obligation in their individual and collective medical practice. Medical educators have a special role in contributing to moralize medical practice. Ethics and HR reflections ought to be connected to clinical and public health case studies. Ethical medical practice requires professionally and socially minded health services and systems. When physicians are commercially financed and industrially managed, this interferes with their autonomy and ethics, because the industry’s profitability depends on commercial, clinical standardization. Commercial insurance companies further reduce access to care while fragmenting and segmenting health systems. You know that. …And do not for a minute forget: Artificial intelligence threatens to make the medical profession obsolete… (Jean Pierre Unger et al)
Claudio Schuftan, Ho Chi Minh City
Your comments are welcome at schuftan@gmail.com
All Readers are available at www.claudioschuftan.com
Postscript/Marginalia
It is useful to distinguish between social movements and social movement organizations –particularly in health
For over a century, there have been people calling for greater focus on the links between poor health and social injustice, oppression, exploitation and domination. We can call all of these expressions and related actions the movement for health. In contrast, the People’s Health Movement (PHM) stands-for and is active-on a particular set of principles, actions, as well as organizing efforts that try to ‘join the dots’ between specific instances and situations and a larger social totality, ‘taking aim’ at particular political economy of health priority issues in order to move the world towards a more just, fair and healthy social order. We thus call PHM a social movement organization that draws on the ideas of the movement for health that represent a vision of what is currently making the world sick and what a ‘social vaccine’ may look like.
The step after that, that PHM follows, is to make it clear that collective action is needed, i.e., joining forces with others, combining and extending the knowledge of each individual in the process. We think it is easy to say that the health movement and its campaigns have had a global impact, but it is much more difficult to say that PHM as a movement organization has had impact –unless one is very clear on what PHM is trying to do. Actually, what it is trying to do is not to single-handedly change the world completely, but instead make solid contributions to changing the world by: changing institutions, getting new concepts/arguments/frames of reference on the health agenda globally, nationally and locally, as well as getting people talking about (and joining in) the PHM approach and ideas in different countries. …And PHM has very clearly done these things in concrete ways over the last two decades. In terms of the concrete and specific impacts that PHM has had, we would be inclined to focus on three out of many other:
• ‘global’ impacts on global-level institutions and discussions (e.g., in WHO, in the Commission on the Social Determinants of Health);
• ‘local’ impacts, particularly in the form of the dissemination of the People’s Health Charter (www.phmovement.org) and other PHM Declarations, the formation of regional, thematic and national PHM chapters and groups, and
• the campaigns, training workshops and other actions initiated by its ‘local’ PHM circles and affiliated groups. (David Legge, Brendan Donegan)