- In most of the world, Health Sector Reforms (HSR) are sick.
They are terminally ill –in part due to the negative consequences of Globalization (G) on the right to health. So we better recognize its symptoms. Denial of the symptoms may be a good temporary defense –but only until reality imposes itself on us.
- This reality is that we have been giving technical solutions to what are political and human rights problems. Ergo, we cannot medicalize HSR any longer!
- I am hereby sending a call for action. Calls for action are not helped by scholarly presentations. When all is said and done, a lot more is said than done…
- We thus have an enormous task in front of us. And to prepare for that task, we need to sharpen our debating skills. We need to awaken the ‘investigative reporter’ in us; to constantly go after the human rights meaning hidden behind the statistics.
- Around the world, what the poor people to be served by true HSR want is simply more: more justice for their entitlements, more from health, more from life, more from history, and more from us!
- Hereunder are about fifty ‘bullets’; they are in no particular order, but are just primers for you to use to start a meaningful debate on this issue:
i-The structural reforms that come with Globalization have negatively affected the most vulnerable segments of society; also, income distribution and economic access to health have become much more unequal.
ii-Civil society needs to become more organized to challenge the power of the states that foster or go along with Globalization and progressively neglect their human rights responsibilities in health.
iii-Civil society needs to increasingly be visible as a credible negotiator between the people and public powers. It has to become a watchdog to contain market and Globalization excesses. They also have to raise the awareness of the people re the challenges Globalization poses. (Best example: the worldwide People’s Health Movement and the Politics of Health website). (www.phmovement.org ) (www.politicsofhealth.org )
iv-The short-run effects of Globalization on the poor ARE negative and significant… So, compensatory policies are being promoted and designed to help the poor to deal with, for example, falling health standards. But this is reactive/palliative and not proactive/preventive…).
v-What are needed are pro-poor/pro-human rights budgets and growth strategies; policies geared towards ensuring that people receive adequate food, education and health care; broad participation in policy design and implementation; environmental and social awareness; and efforts to combat discrimination:
‘As individuals, we beg; collectively, we demand’.
vi-With Globalization, the non-poor benefit disproportionately from public spending, their benefits far exceeding the taxes they pay.
vii-Pro-poor structural reforms we so much talk about are yet off-limits for the macro policy establishment. At the macro level, ‘the social’ continues to be an afterthought. But macroeconomic policies should add on to social policies if they are to achieve poverty reduction. So far, Globalization treats social welfare as an optional extra.
viii-More often than not, ‘sound’ macroeconomic policies are designed and then social ‘band-aids’ are applied in order to achieve acceptable outcomes.
ix-The social exclusion inherent in neoliberal growth models should simply be rejected. We should accept nothing less than social inclusion of the poor.
x-With Globalization, the trend is thus toward a drastic reduction of state-based entitlements and their replacement by market-based, individualized entitlements… But the invisible hand of the market has no capacity to create a decent, human rights-based society for all. The law of supply and demand can fix the market price of bread, but it does nothing to alleviate hunger, famine and ill-health.
xi-Moreover, with Globalization, priority is granted to efficiency over other values such as social justice or environmental sustainability.
xii-We now have to think globally and act both locally and globally.
xiii- Following the Globalization orthodoxy, recommendations are made these days to privatize social protection (but privatizing basic social services and social insurance is antithetical to redistribution and equity… The idea that any pivatization is better than no privatization should be rejected.
xiv-In sum, the negative effects of Globalization are reversing some of the social gains already made; it is lessening the likelihood that developing countries will have the necessary policy autonomy and fiscal capacity to carry out and finance comprehensive health policies.
xv-Although NGOs have enjoyed a high profile in recent years they have mostly remained in the reactive mode. There are signals that their heyday is over. Many stand accused of complacency and self-interest on the one hand, and of being ineffectual and irrelevant on the other.
xvi-Globalization has brought about a shift in power: the nation state has weakened and there is a reduction in social accountability. Moreover, ‘in the dealings of Globalization’, its intricate connections are so patently disguised as to become almost invisible. Or worse, the deceptions are so brilliantly woven into its processes that falling for those deceptions is deemed as both fashionable and progressive.
xvii-Due to these negative consequences of Globalization, communities in many Third World countries are no longer able to cope –their previously successful coping strategies diminishing daily.
xviii-Governments in the Third World are simply assumed to be incapable of assuming a minimum level of welfare for their citizen. It is implied that it is necessary to look for alternatives in the private sector or to directly privatize services (…and NGOs are occasionally a convenient form of privatization). Only that, often, such privatization strategies lower the quality of services for the poor and end up widening the gap between the rich and poor.
xix-Under Globalization, the annual losses to developing countries run at an estimated $500 billion –an amount much higher than what they receive in foreign aid.
xx-Whatever the response, promoting the economic benefits of Globalization requires mechanisms to prevent its excesses –including the human rights violations it aggravates–, because there is a clear trade-off between market efficiency and the social welfare of workers and peasants.
xxi-In the international scene of (mercenary) technical development assistance, for example, issues of substance are turned into technical matters by paid consultants while underlying more structural issues get obfuscated. Or –what amounts to the same– aid agencies too often remain unwilling to respond politically to political situations.
xxii-Remedies proposed to specifically increase equity and access to basic services thus include targeting of subsidies (i.e. selective subsidies of goods and services disproportionately consumed by the poor), prepayment plans (e.g. community-based health insurance), exemptions and the selective dropping of some fees (e.g. health and educational), prevention and on improvements of the quality of care (in health), as well as on a fairer urban/rural distribution of resources.
xxiii-Expenditures on health have to increase, they say, but to be equitable, they have to be concentrated on preventive activities in rural areas and should be targeted to the lower income quintile.
xxiv-Globalization may be inevitable, but what it looks like is not –there are forces that can shape it, and human rights must be one of those forces.
xxv-Actually, with Globalization, “Might is Right” has come back with a vengeance. And in a defeatist stance, we have so far accepted this fact and have bowed to the forces we think we cannot effectively oppose. Soft approaches will not do. Bolder steps will have to follow.
xxvi-Furthermore, we have to fight the indifference of our youth to the present global situation: our young and upcoming colleagues. We have thus to enroll the youth before they resign themselves… Our youth seems more interested in the information superhighway.
xxvii- In sum, an effective challenge against Globalization and its negative effects on health is possible, but demands the same kind of intellectual commitment and vigor that characterized anti-colonial or independence struggles.
xxviii-Western intellectuals have simply abandoned their commitment to challenge the exploitation and oppression of the poor as they continue being brought about by Globalization. Concerted campaigns and struggles against poverty, tyranny any exploitation will form the only sustainable basis of an intellectual renaissance of our youth and of ourselves.
xxix-Taking a minimalist stand towards Globalization will do no harm, but neither will it do much good. Inertia in history (has) and will always work(ed) against the more visionary and radical changes deemed necessary when the same fall outside the ruling paradigm.
xxx-Development cooperation must thus become more political and more human rights oriented, because only structural reforms will deliver sustainable and fair development.
xxxi-The solutions to the consequences of Globalization on the health and nutrition sector, for example, cannot be medicalized any longer. Technical assistance focused on health/nutrition matters only is not enough to uproot the structural inequities underlying pervasive and unrelenting ill-health and malnutrition in the world.
xxxii-But the inertia is so great and our collective virtual view of reality so distorted and entrenched, in part due to Globalization, that the likelihood of us changing that reality remains dim.
xxxiii-In short, we need to give a larger intellectual and political scope to our discussions on Globalization. In doing so, we have to manage to develop a political program of more universal appeal. We need to come up with a focused common agenda.
xxxiv-When economics has ceased to strengthen social bonds and its prescriptions are actually further pauperizing millions, it is time to start thinking in political terms again. This is one of my cherished iron laws.
xxxv-The facts discussed here are more than enough to allow us to go negotiate (or struggle) for new more radical equitable/pro-poor/pro-women/pro-human rights based strategies on the highest of moral grounds.
xxxvi-Globalization does not have a human face; power differentials are at its crux. It is a process we cannot wish away.
xxxvii-When government expenditures in health in developing countries are shrinking, the World Bank has them pushing for a greater role of market forces in the production and distribution of health.
xxxviii-Providing health care as a human right and on the basis of need is being replaced by a system based on cost recovery where exemptions for the poor have not worked.
xxxix-Safety nets are nothing but a way to manage poverty attenuating social unrest.
xxxx-The politics of health will override all other efforts to bring us Health for All. (Equity is the forgotten key thrust of Alma Ata!…this year in its 25th anniversary!). A renewed commitment and resolve to foster empowering community-based activities will have to guide our actions.
xxxxi- Countering the forces of Globalization is a step towards equity; it is futile to look for an accommodation to fit greater health into an inherently inequitable system. This, because some of the HSRs measures are actually Structural Adjustment measures in disguise.
xxxxii-At the same time, reforms being proposed to strengthen public health policies and public financing of health via taxes are being dismissed as being supposedly non-viable. But the so often proclaimed non-service mindedness of the public sector is not a given; we need to fix a system that, granted, has many flaws. But it also has many strong points!
xxxxiii-Evidence that market-oriented health care systems are more efficient are not really well founded (look at the USA…); they are just more profitable to some and too often provide unnecessary care.
xxxxiv-Conversely, evidence that public health care systems are more equity-oriented and can be made more efficient, does exist.
xxxxv-The cost recovery system is a regressive tax in which the poor pay as much as the non-poor; becoming sick thus penalizes the poor more, and high fees for health care are a major cause of pauperization.
xxxxvi-Direct and indirect progressive taxes (and non-private insurance schemes) must thus constitute the financial basis in an equity-oriented health care system.
xxxxvii-So, if our objective is to provide care according to need, our only choice is to improve public health care systems that cater to those with less ability to pay (the majority).
xxxxviii-Another perennial problem of HSRs is that decision-making has allowed limited involvement of the beneficiaries themselves.
xxxxix-Bottom line, HSRs have been used as crutches to pretend one is changing the system, but basically staying the course or even going backwards. And this is not by accident…
L-HSRs alone cannot simply address the human rights and structural constraints to equitable health, not even with good targeting.
Li-Tinkering with the current HSR models will simply not do. This is the sad reality. Precious time is likely to be lost only to see the problems of inequity worsen…and what is inequitable today will be inhuman tomorrow.
Lii-So what would be more effective and sustainable?
- a) First, it is not for us in this distinguished virtual gathering to come up with the responses.
- b) For once, it would be best to ask the beneficiaries directly to respond to this question rather than coming up with some technical responses.
- c) A bottom-centered approach calls for a radical change in our priorities and our modus operandus: The locus of control has to shift to the beneficiaries.
- d) The bottom line is that –together with the beneficiaries– we need to articulate a more sustainable Equity-Oriented Health Sector Reform (EOHSR).
Liii-There is no such a thing as ‘lack of political will”. What there is, is a laissez-faire, the manifestation of a choice made, i.e. a choice not to exercise a will!
Liv-Contradictions between ministries of health and the people they say they serve have not changed a bit with the (often foreign-driven) HSR as applied in many countries worldwide.
Lv-Who wins/who loses? What is won or lost? How, through what mechanisms? and Why? –these are the kind of questions we are not asking.
Lvi-We need to get involved with beneficiaries in consciousness raising, increasing their rights awareness and their political awareness of why they are where they are.
Lvii-In short, what is needed now is a start-over, a global movement, a grassroots revolution around the right to health.
Claudio Schuftan, Ho Chi Minh City