[A People’s Health Movement contribution to the World Health Report of 2008].
Aid money has rained on jungles, plains and deserts for 30 years; in the end only poverty has grown. (SID)
1. This Contribution departs from the premise that, on the ethical issues of primary health care (PHC), as well as on considering health an inalienable human right, the People’s Health Movement (PHM) and WHO can and do agree. But can they get a step closer politically?
In that context, it behooves to ask:
2. What exactly is meant by WHO ‘a more integrative approach to the problems of PHC’ –as the August 2007 outline for the World Health Report 2008 (WHR08) says. Does it mean a more multidisciplinary approach?, a more holistic one?, a more systems-oriented one? or a more political one?
[PHM thinks these terms need to be clearly defined in WHR08 –and a position must unequivocally be taken by WHO].
3. Changes are clearly needed; WHO and PHM agree on that as well. But will incremental changes (‘patching up’ the PHC approach) lead us anywhere? If not, what does WHO think are the ‘non-incremental’ changes needed? (WHR08 outline)
[PHM fears that another step towards just the peripheralisation (or ruralisation) of health care will work against the comprehensive PHC it deems is needed…and that is what is really at stake here and now. Similarly, PHM is very clear about the difference between the mere dissemination of health services to higher percentages of the population, especially in rural areas, and changes in the health system that question the character of its structure. Therefore, PHM’s objective is clear: it is to work on a political-economic-approach to the health-and-disease-problems in both developed and underdeveloped countries. PHM is conscious that most doctors have a problem with this; it, therefore, thinks that the role of physicians, as perceived by Franz Fannon many years ago, is still valid today].
4. First and foremost –and being totally dispassionate– WHO senior cadres have to ask themselves: Has WHO lost its sensitivity and its touch with the non-technical, social determinants of health issues and thus with real people’s PHC needs? Does WHO thus need to break out of the box it-is-in right now?
[PHM thinks the time for this has come. The creation of the Commission on the Social Determinants of Health is seen as a step in the right direction. But what remains to be seen is if WHO will follow the Commission’s recommendations after July 2008 when the final report is due].
A related question is:
5. What can WHO do about health planners in its midst that focus-on, select and prescribe health measures without doing something about the causal elements they take as given-and-unmovable and that are responsible of most preventable ill-health, preventable malnutrition and preventable deaths the world over?
[Conversely, PHM sees its struggle for comprehensive PHC as a port of entry to fight for structural changes in society as a whole].
Consequently:
6. Because the root causes of preventable ill-health are its social determinants, does WHO share with PHM the line of argument that we will need to add to the village health workers’ skills the ability to stimulate local awareness, to organise and to mobilise local communities to become involved in shaping and demanding a new, comprehensive PHC approach as is needed in the 21st century?
[PHM keeps in mind the ‘promotores de salud’ in Central America that were brutally repressed and killed in the 1970s, but is of the opinion that these workers should indeed get involved in social mobilisation around health issues in the community].
Three further questions for WHO are:
7. Is the main PHC problem in 2007 one of scarcity of resources or of scarcity of democracy in decision-making processes where power plays a key role in determining where health budgets go?
8. Is PHM right to be worried about the percentage of national health budgets that are allocated (top-down) to vertical programmes, especially with so many public-private partnerships (PPPs) in operation in the developing world? Does this not worry WHO?
And in the same context:
9. Would WHO agree that health services can and do act as social control institutions?
[PHM thinks that the allocation of health resources is a legitimating tool (both for the rulers and the ruled) and thus ultimately reproduces class relationships. The bias in this allocation is seen as one of many recipes of domination reconciling power and beneficience. Ergo, the type of state, and the class relations in it, are predictive of the nature and the direction of health care allocations –especially as relates a) to health resources as a percentage of GNP, b) to the per capita allocation for health, c) to the allocation of funds for primary, secondary and tertiary health care, d) to the balance between urban and rural services, and e) to priorities for health expenditures in relation to endemic disease patterns].
And along similar lines:
10. Is making explicit the precise relationships of poor and ethnic minority communities with class divisions something that needs to be done in each country? If yes, are class-analysis and class-struggle in any way an element considered in WHO situation analyses? Are the same needed to look at the major and minor contradictions in health in the right perspective?
[PHM thinks class and gender are as important as race and ethnic background in determining access to health].
Moreover:
11. How much influence and impact will all the scholarship within WHO have if the same is restricted to professional journals, to declarations and/or to World Health Assembly resolutions with no teeth? Is it sufficient to be scholarly and technically right?
12. Do WHO cadres keep dreaming we can reverse the maladies of society…if only we all do our technical work better and more efficiently?
[PHM thinks that when scholarship and activism compete for our time (including that of WHO cadres) it is activism that tends to be pushed aside].
13. For 50 years, WHO has lobbied for research funds to study the world’s major health problems on the grounds it has a unique contribution to make to solving those problem. But has it really contributed as much as it should have?
[PHM thinks that even making research results available to well intentioned health officers will not make a difference, because current research priorities in WHO are not yet sufficiently linked to the social determinants of health (SDH) and to the macroeconomic and political issues behind them].
14. But does WHO perceive that such research on the SDH has to focus on the coping and adaptive strategies used by poor and marginalised people whose access to health is limited?
[PHM feels that such research will only lead to accommodation, to targeting and to more top-down ‘pat solutions’ that fall in the realm of promoting positive deviant behaviours that do not address the structural causes of poverty and that thus only perpetuate preventable ill-health, preventable malnutrition and preventable deaths for the majority non-positive deviants].
15. Can WHO, therefore, continue to have faith in theoretically sound solutions that, for political reasons, cannot be implemented or can be implemented, but do not change the SDH?
[PHM thinks it is poverty rather than any microbe, parasite or worm that is the key vector of preventable ill-health, preventable malnutrition and preventable deaths].
16. Does the above then mean that WHO needs to sponsor more participatory research, de-facto involving the researchers in community consciousness raising and mobilisation?
[PHM thinks that, as a misconceived substitute, governments (very often prompted by WHO) get involved in a repetitive collection of some health statistics that bear no relevance to the changes really needed in the health care system].
Furthermore:
17. Can WHO agree with the premise that implementing comprehensive PHC can be the basis for developing the political strength, the organisation and the awareness of poor and marginalised people in their struggle against underdevelopment and the preventable ill-health, preventable malnutrition and preventable deaths that come with it?
18. To what extent, then, does WHO think that democratisation of the health sector can be independent of democratisation of all institutions of society? And if it deems health cannot be independent, does WHO understand that what is needed is to go from:
community organisation,
to continued participation of its members,
to their conscientisation (politicisation),
to their mobilisation for self-help, for lobbying and for placing demands (practical politics),
to the consolidation of movements through extensive networking and through solidarity work with those whose health rights are being violated? …and, last but not least,
to face the foreseeable repression this may bring about?
[PHM thinks that people whose access to health is denied must go from felt needs to mounting an effective demand; and, for that, they have to a) organise, speak up and gain voice and influence, b) ask the relevant whys?, c) question their lack of power in decision-making, and d) politicise the debate and the issues on the denial of access to health. As a corollary, PHM sees itself as a denouncer of the many contradictions in the current health system and as proactive change agent of the same].
19. Does the above mean that the beneficiaries must undergo an apprenticeship in new and higher forms of direct participatory democracy for the needed changes in PHC to happen? If yes, is WHO (with the help of PHM) prepared to be a protagonist and a leader in promoting such an approach? (The underlying two questions to this are: Is local direct democracy an absolute necessity for successful comprehensive PHC or does representative, electoral democracy suffice? and, How difficult is it to install such a direct democracy?).
[PHM thinks that the fundamental changes needed to implement comprehensive PHC are not possible without conflict with the powers that be. PHM also thinks that changes will only occur if all stakeholders promote and participate-in steps leading to an active engagement of user constituencies].
Moreover:
20. To what extent does WHO think that the progressive resolution of the structural determinants of ill-health will significantly minimise the inequities in women’s and minorities’ health status? If they agree these determinants play a key role, should WHO spend more energies and funds on tackling those social, economic and political issues?
[PHM’s People’s Charter for Health (www.phmovement.org) is clear about how the resolution of these inequities requires addressing the social and cultural determinants of the same].
21. How can WHO avoid the risk that the ‘new PHC’ in 2008 again falls in the trap of importing preconceived packages that only partially (or not at all) tackle the health needs of local populations and actually maintain the status-quo?
22. What does WHO think has been the role of the international financial institutions (IFIs) in imposing such packages (that have only led to the massification of the pathology of misery)?
[PHM is against any imposition of pre-packaged solutions by the donor community].
23. Has WHO failed in giving member states support and a different advice than that of the World Bank about what to do to launch a comprehensive PHC approach to solve their major health problems? If so, why?
[Together with others, PHM strongly believes WHO has indeed failed].
Otherwise:
24. What is WHO’s take on the role of the transnational pharmaceutical houses (and of IFIs) in shaping the prevailing political economy of health? Does it still see fit to engage in PPPs with them?
[PHM is opposed to the current shape of PPPs WHO is engaged-in (as well as to the private sector earmarked funding of WHO programmes and activities) and has asked WHO to reconsider its position on these two contentious issue].
25. In societies with what social order does WHO think can a collection of mostly vertical and preventive programmes (even if well-funded) constitute building blocks for more equitable and effective health services?
26. Does WHO share PHM’s sense of urgency as regards the need to change the training curricula of our young upcoming professionals so as to give comprehensive PHC a more central role in their learning? (Includes new courses for undergraduates and graduate students, as well as new curricula for continuing education). What is WHO prepared to do about this?
The bottom line:
27. Many solutions will be proposed in WHR08: How is WHO going to blow life into them? What is WHO going to concretely do?, i.e., how relevant will WHR08 be to improve the health (or even to avoid one single death) of, for example, children in the world? How relevant will it be to improve the quality of life of a single poor human being?
28. More importantly, will passivity in giving comprehensive PHC a renewed emphasis and boost make WHO an accomplice of the status-quo?
29. To avoid such a passivity, ought WHO go from an ‘accommodation-mode’ to a more ‘issues-confrontation-mode’? [PHM thinks it should].
30Ultimately, to use a worn cliché, in the revival (or rescue) of comprehensive PHC, will WHO be part of the problem or of the solution?
cschuftan@phmovement.org for PHM.
Claudio Schuftan, Ho Chi Minh City.