1. Ministries of health around the world claim they have carried out ‘a’ health sector reform; they argue that by doing so, they have decentralized and devolved the governance of the health sector closer to the beneficiaries and thus have furthered the human right to health (RTH). [But have they really?].

2. They further claim the stimuli for these reforms come (came) from the beneficiaries themselves. [But nothing could be further away from the truth].

3. In many countries worldwide, contradictions between ministries of health and the-people-they-say-they-serve have not changed a bit with the (more often than not foreign-driven) health sector reforms applied in the last two decades.

4. A dialectical analysis of the situation would bring this up clearly. But we do not think dialectically anymore; dialectics (analyzing inherent contradictions) is supposed to have died with the fall of communism in the Soviet Union. But dialectics is independent of communism; it is an analytical tool that brings out the contradicting interests of social classes in a given society….and the health sector is a sector that –from the human rights perspective– badly needs to be looked at dialectically if we are ever to solve its multiple (and growing) problems.

5. Issues of how power and control are exerted are (and have always been) behind the state of affairs we see right now in how the health sector, in no-matter what country, violates the RTH.

6. Who wins/who loses? What aspects of the RTH are being violated? How and through what mechanisms are they being violated?, and Why does such a state of affairs continue? –these are the kind of questions we are not asking, my dear Watson.

7. We need to bring up such an analysis of dialectical relations in health to find the current disparity favoring the rich, because decisions and inputs (or the lack of them) are mostly controlled by those in power. Why is such an analysis (and action thereupon) needed? [Because no lasting social progress has ever come from the ‘benevolence’ of the haves].

8. Only once we shift our analysis, for it to focus on the inherent contradictions of the health care sector and of the political system that upholds it, will we realize that we are facing a skewed relationship in which groups of claim holders, that are supposed to be involved in a struggle for their human rights, are not engaged in a real struggle right now. This results in there not being a real opposition from them to the policies imposed on them from above (and from abroad –and from international organizations at that). Ergo, beneficiaries-that-are-not-benefiting are passive in defending their RTH.

So, what is needed to get into a dialectical analysis and into the actions flowing from it?

9. We need to get involved with claim holders in consciousness raising, in increasing their political awareness of why-they-are-where-they-are. (Using the “Yes, but why?” didactic technique is a good approach: We ask people for the causes of what they see/experience as the unmet needs in their health care; as they respond, we then keep asking “yes, but why that?” and so on, to their subsequent responses until they get to the underlying and basic, structural causes that eventually reveal the more hidden power issues).

10. Otherwise, we have to open up the dialogue towards topics of:
• equity, and health as a human right,
• effective decentralization and devolution of power (democratization) [the latter two already called for by the Alma Ata Declaration 30 years ago…],
• the role of Globalization on the current state of affairs in health,
• the role of international financial institutions (WB/IMF), the WTO and the role of donors, the UN system and NGOs…

11. And on the more technically side, cover topics such as:
• the fee-for-service system versus social health insurance,
• local health systems development and primary health care in the 21st century,
• essential drugs, over-prescription and abuse of injections,
• community-managed health programs and co-management of health facilities,
• joint-decision making…

12. These are just some of the tactics to follow to more dialectically and proactively engage in redressing violations to the human right to health. More elements to use in the struggle should and will come from the claim holders themselves once they are mobilized. We, my dear Watson, should not be prescriptive, but just help open this new avenue for claim holders to express themselves.*
*: We do not even have to reinvent the wheel: see the People’s Charter for Health at www.phmovement.org

13. In short: What is needed now is a start-over, a movement, a grassroots revolution in health.
‘Elemental Watson’!

Claudio Schuftan, Ho Chi Minh City
cschuftan@phmovement.org

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