[TLDR (too long didn’t read): If you are reading this, chances are you care about HR. This Reader covers different aspects of the political economy of health and how we ought to understand and apply it in the context of ongoing discussions on Universal Health Care and HR. For a quick overview, just read the bolded text]. Traducir/traduire los/les Readers; usar/utiliser deepl.com
1. For many of us, the political economy of health is concerned with how political and economic domains interact and shape individual and population health outcomes. It employs critical theories of discrimination, racism and inequality to better understand the roles of class exploitation and oppression in epidemiological patterning. (Michel Harvey)
In theory, the World Health Organization is the coordinating agency for global health: How is it fearing (in general and during COVID)?
2. Influential private and public actors have claimed (overtaken?) the relevance and central role of this UN agency. In practice, paradoxically, the money globally budgeted for health goes largely to other institutions and not to WHO. New institutions and mechanisms have been created to which funds are channeled (The Global Fund, GAVI, Act-A, COVAX, CEPI,* etc.). These institutions or mechanisms are, in most cases, public-private partnerships where the pharmaceutical industry is usually present. Official Development Assistance is important, but represents only one per cent of what developing countries spend on health. How much is spent to promote global health and where this money goes is the subject that worries us. After the experience with COVID-19, a fundamental question that must be addressed is how the global public interest can be preserved by creating common public goods and protecting human rights in the prevention, preparedness, and response to present and future pandemics. (South Centre)
*: https://www.google.com/search?client=firefox-b-e&q=global+fund , https://www.gavi.org/vaccineswork/covax-explained , https://www.who.int/initiatives/act-accelerator , https://www.google.com/search?client=firefox-b-e&q=CEPI
3. Not being facetious, it is important here to foreground the vital role played by heterodox actors during the pandemic. Heterodox global health actors are backgrounded actors who improve health in different parts of the world, but who remain politically marginalized and invisible, because they depart in crucial respects from the liberal orthodoxy pervading the field of global health governance. (Stefan Elbe et al)
A word about health care financing
4. Financing and health are disciplines that have developed separately. Unfortunately, the problem is the following: the moment you leave that space to the technical people, each becomes a technical issue. And yet we have not dealt with the philosophical issue or the underpinning social thinking that should come with it, i.e., we do not make the indispensable connection to the progressive achievement of the right to health. From a financial perspective, we have always put the people who give the money as the ones who call the shots. (He who pays the piper calls the tune …including at WHO). As a result, ‘we the people’ lose out to the-people-that-make-decisions-for-them who are too distant to the problems on the ground. This is where we have to find an integration between the politics, the lobbying and the technical expertise. We have to move away from the power dynamic of wealth calling the shots. Big names are not what it will take to get the job done. (Attiya Waris)
Take a burning example given the discussions being held on this topic at the UN:
Replacing PHC with UHC threatens to be one step forward and two steps back for health policy and for the right to health
–It is impossible to have healthy people on a sick planet. (Shweta Narayan, Rico Euripidou)
5. In 2018, the 40th anniversary of PHC was celebrated at Astana where references were repeatedly made to ‘quality PHC’ when it was clear that, really, primary care was meant, i.e., as care at the first level of contact with the formal health sector. Formulations such as “primary health care is essential to achieving universal health coverage” portray PHC as a means to attain coverage of health services, whereas equitable access to basic health services has always been a component of PHC. As stated in the widely supported Alternative Civil Society Astana Statement (2018. https://phmovement.org/alternative-civil-society-astana-declaration-on-primary-health-care), the Astana Declaration inverted one of the means to achieving PHC whereby UHC became the goal. This risks further medicalizaing and commercializing health care under the UHC model that is heavily based on modeling** and is influenced by external financing. Although the Declaration of Astana frequently invoked PHC, it gave scant attention to the drivers of ill-health and inequality —PHC’s social determinants. There is also no hint of the need for a new global economic order (NIEO) for the fullest attainment of health for all (as explicitly called-for in Alma Ata). By reducing PHC to a cornerstone of UHC, as opposed to an umbrella under which UHC resides, the Declaration of Astana confined the health sector to a much more restricted role. (David Sanders et al)
**: It may be that the disease burden for LMICs is significantly under-estimated, because most of the estimates are based on modelling, done with very limited primary data (extrapolations are dangerous).
Addressing how the global public interest can be preserved when, at the same time, protecting human rights
6. This focusing on the true public interest was a particularly contentious issue during the COVID-19 pandemic. But there is an important precedent that was overlooked by many who protested HR were being violated –and some may well have been… But here are the Siracusa Principles that many of you may not be aware of. Let this Reader introduce you to them.
Siracusa Principles (https://www.icj.org/wp-content/uploads/1984/07/Siracusa-principles-ICCPR-legal-submission-1985-eng.pdf )
7. As stated in General Comment 29 of the HR Council on HR during states of emergency (https://www.refworld.org/docid/453883fd1f.html), HR can be temporarily limited by ensuring that such limitations:
- Are provided-for and carried out in accordance with the law;
- Are based on scientific evidence;
- Are directed toward a legitimate objective;
- Are the least intrusive and restrictive means available;
- Are neither arbitrary nor discriminatory in application;
- Are of limited duration; and
- Are subject to review.
8. Towards this end, each Party shall:
(a) incorporate into its laws and policies human rights protections during public health emergencies, including, but not limited to, requirements that any limitations on human rights are aligned with international law, including by ensuring that: (i) any restrictions are non-discriminatory, necessary to achieve the public health goal and the least restrictive necessary to protect the health of people; (ii) all protections of rights, including but not limited to, provision of health services and social protection programs, are non-discriminatory and take into account the needs of people at high risk and persons in vulnerable situations; and (iii) people living under any restrictions on the freedom of movement, such as quarantines and isolations, have sufficient access to medication, health services and other necessities and rights; and
(b) endeavor to develop an independent and inclusive advisory committee to advise the government on human rights protections during public health emergencies, including on the development and implementation of its legal and policy framework, and any other measures that may be needed to protect human rights.
9. Food not for thought, but for action when the next pandemic comes around…
Claudio Schuftan, Ho Chi Minh City
Your comments are welcome at schuftan@gmail.com