1. Weak health systems are infringing the human rights (HR) of both patients and health workers. Therefore, and because they are not currently doing so, health systems are to be reorganized to give social action and empowerment greater preeminence*: That is where I see one of the key challenges lies for WHO.
*: We here understand empowerment as a concept that challenges established hegemonies and bases itself in the human rights discourse. Empowerment is not just about knowledge; it is about the recognition and the building of abilities to change power relations in society. Outside agencies cannot and do not empower anybody; they may facilitate, but ultimately it is the people who wrest power and thus need to empower themselves. Empowerment to achieve development (and health) means changing the causes of inequity, changing economic relations, changing conditions of work and of living, and securing access to resources so as to change the power relations that determine preventable ill-health, and malnutrition, as well as excess deaths. Even in a remote village or a slum, the struggles for development, for health and for social justice, are inseparable from the global struggle for a more just world economic and social order. (Amit Sengupta)
2. A sample of just four symptoms of where the health systems have gone wrong (mostly following WB-sponsored and WHO-condoned health system reforms –which will be covered in the next two HR Readers) is as follows:
i) We are all aware of the ever-shrinking budgets for the public health sector in most poor countries. Add to this the South-North brain drain of health personnel that is catastrophically affecting the availability and quality of health services in many of those poor countries. [And this, while health tourism is flourishing in some of the countries with huge disparities in access to health; health tourism is creating important islands of internal brain drain from the public to the for-profit private sector and is draining scarce resources for health within those countries].
ii) The health systems required to deliver the needed prevention and care for AIDS are more than weak in the most affected countries –a fact that was overlooked for over a decade. Moreover, AIDS is not only receiving the lion’s share of international aid (with all the distortions this brings to the health sector), but AIDS is now increasingly being considered an opportunistic disease in poor people. [So, how much is WHO, in concert with other agencies, doing about poverty…?].
iii) WHO is party to dozens of public-private partnerships, many of which have perpetuated vertical approaches to mostly single disease control strategies. [How can this be reconciled with WHO’s 2008 newly-found (re)dedication to PHC?].
iv) The promotion of private health insurance schemes for the middle class has been a chronicle of hidden restrictive clauses in the small letters of insurance policies, and of ‘cherry picking’ practices that reject patients with chronic underlying conditions leaving them for the public sector to deal with. On the other hand, although community-based health insurance schemes have been hailed as a health care financing breakthrough, it actually pools premia only from the poor themselves. This clearly betrays the solidarity principle of cross-subsidies that any equitable insurance system should bring about. Not engaging such solidarity mechanisms results in segmentation in the provision of health care services.**
**: To explain the latter, let me bring up a metaphorical example of a lunch party in a pricy restaurant: Three persons are invited. One is able to pay in full and gets a sumptuous menu; another can only afford half the cost and gets a poor menu; the third person, who cannot pay, gets bread and water. The three can say they attended the lunch at this expensive restaurant –but they are not treated equally… Insurance schemes for the poor mostly offer minimum/basic packages of health care. All invited must have the right to the same meal! (i.e., vaccines yes, but cancer drugs no??). (Aarmando Denegri)
3. The quest for health equity is often rightfully used as the major argument against privatization and for greater government involvement in health care. But WB-sponsored and WHO-condoned health system reforms have kept pushing for the elusive and unattainable principle of “those who can pay should pay”. Nothing terribly wrong with this. However, we are told that private outlets are the best suited to apply the principle… This, despite the fact that case after case has shown that poor populations are consistently left behind and out in initiatives that try to apply that principle.
4. The question in all the above is: How is all this compatible with WHO’s Constitution and thus with its mandate? It is true WHO is, in a targeted way, active in some of these areas: sometimes taking a position compatible, sometimes incompatible with the HR-based framework that should rule over all its actions. An inconsistency clearly exists.
5. The HR framework stands squarely against the push for privatization and against considering investments in health as a means to increase productivity and to support the ‘global security’ discourse in relation to development assistance in health –as the Macroeconomics and Health (Sachs) Report clearly did in 2001.
6. There is no way around for WHO: Health must be defined as a fundamental HR (we note here that there is no such a thing as a basic HR! all human rights are basic). This is of crucial importance as the HR framework is entirely different to the Basic Needs Approach in shaping the entire manner in which all needed measures must be taken to meet the health needs of all (and we are all born with this right). Health is a public good; and this means that people’s health is not just another good that can be left to market forces.
7. This also has profound implications in the need to change the curricula of health (and nutrition) professionals’ training programs so that they more decisively emphasize the HR-based framework, as well as public health and public nutrition. The current system of training future colleagues has yet to be replaced, and this is clearly another area WHO should be more active in. There has been a long discussion whether we are training activists or ‘engineers’ that apply mainly technical measures. Mostly engineers are being trained/produced (Alan Berg). In the last decades, engineers have not succeeded in solving the big health and nutrition problems; faculty members of training institutions have not been commensurately retrained; and students and alumnae have not been involved in discussions to push for the curricular changes needed. The ‘engineer-activists’ we really need are not being produced, those who understand the HR, social and political determinants of preventable ill-health, malnutrition and excess deaths –as well as become involved in the more structural measures needed to overcome them. [Ergo, should we be surprised of the ongoing status quo? Or more importantly, what should WHO be doing in this realm?].
8. So what next?:
Can WHO be the engine of change to overturn these realities? It has to!
How is it to interact in a new way with member states (and universities for the training aspects) who are the ones that must ultimately do the overturning? [WHO simply has to find the ways, now!].***
***: WHO’s Commission on the Social Determinants of Health and the PHM/MEDACT Global Watch II (2008) point towards viable alternatives. (www.phmovement.org) WHO is urgently called upon to incorporate these –and for this it will have to undergo serious restructuring.
9. Finally, one cannot but ask the question: Is all that needs to be done too expensive to do? … or will it be more expensive not to do anything? I am afraid we have not even yet reached the point where the central question is one of money…we are even before that stage. How I wish I were wrong…
Claudio Schuftan, Ho Chi Minh City
cschuftan@phmovement.org