Say it loudly, say it often
-Public systems must be reclaimed by citizens and reformed in the interest of people so duty bearers are decisively made accountable. (This quote is meant to stimulate you to reflect about what needs to change).
-Yes, there are considerable potential risks and obstacles in the road to achieve the fulfillment of human rights of all. Nevertheless, the status-quo can simply not linger on.
1. Mind you, we have been through a 40 years-old uncontrolled experiment in neoliberal globalization –its dominance having begun in the early 70s.It was rolled out in three phases: structural adjustment, financialization* and austerity. Neoliberalism was never about eliminating the state; instead, it was about occupying it, reconfiguring both the state and the market so that they became thoroughly enmeshed. The experiment reduced social protection, increased user payments for social services, it privatized state assets, increased public private partnerships (PPPs), eliminated food and fuel subsidies; additionally there were wage bill cuts, a reduction of safety nets expenditures, pension reform to delay eligibility for retirement, reformed public health systems and a broadening of consumer taxes to include items disproportionately consumed by poor households.Among other, this increased homelessness, dependence and reliance on low cost, highly processed obesogenic food, increased stress levels, as well as suicide rates. Add to this increased unemployment, increased people working in short term jobs with no benefits and the harmful health effects of austerity with a fall in median wages disproportionately affecting women workers: all HR violations!
*: Financialization refers to periods where financial markets dominate over the traditional industrial economy and agricultural economics.
2. But there is more: Take transnational corporations (TNCs). They rarely invest their profits and dubious tax savings in new economic productive activities. The net effect of tax cuts granted to corporations in this period has been a redistribution of capital from the public to the private sector.** This is nothing short of Capital-Accumulation-Through-Dispossession. Never forget that a small redistributive tax on the richest quintile of the world would have a far more dramatic impact on poverty and inequality reductions than conventional trickle down growth.
**: Taxes are the price we pay for civilization. (O.W. Holmes) They are also the price we pay for decent and equitable health and other social services: that is the activists’ take home message. (Note that, over this period, the WB has consistently pushed for ‘basic’ rather than for truly comprehensive public services).
Freeing governments from their neoliberal prison is one of the most important political tasks of human rights activists
Those opposed to the welfare state never waste a good crisis to impose more austerity. Public health and other development professionals must not remain silent at a time of financial crisis; they need to develop and get involved in strategies of activism; they must act against economic deprivation and political suffocation. (DavidStuckler)
3. Many people mobilize in anger for-a-time, but it takes a more inclusive vision to figure out how we ought to organize and support people mobilizingso that a true process can sustainably take us forward. What we ultimately need to aim-for is an economy that is not driven by maximum profit for the few, but by the fulfillment of the human rights (HR) of the many.
4. But we must not be fooled. After the onset of neoliberal reforms, aggregate economic indicators may improve, however at the expense of equity and equality. In fact, liberalization and structural adjustment policies have severely undermined what was before a well-developed social protection system. Under neoliberalism, old social classes with ties to all political branches find themselves standing upright regardless of who takes power. And although we may have ‘new regimes’ these follow older policies, sweeten them for political consumption thus ensuring that there are unchanging elements that maintain power regardless of who is now in charge.
The neoliberal prison in health
5. Much is being said these days about Universal Health Coverage (UHC). But also, much of what is said, does not propose a unified, all-encompassing system of public provision.***(Coverage rates are usually presented as averages thus hiding often enormous inequalities!). The UHC model talked-about-most provides ‘choices’; yes, but within a particular political and economic environment that is not neutral. The dominant neoliberal environment can and does exploit the ambiguities of the UHC model and pushes a model that is market driven –an anathema to what the human right to health stands for. We understand efficiency in health care not in the way used in a market environment, but in terms of the returns achieved through investment in a public good!
***: Nothing would challenge the power of private service providers as much as quality, accessible public sector health services. (Jean Pierre Unger…)
6. Historically, health care systems worldwide have been shaped by labor’s fight for better living conditions through the extraction of better terms from the ruling classes.
7. Therefore, the loss of national public health services signals a profound failure of organized labor exerting sufficient pressure. Simply put, public interest and common sense are defeated by neoliberal ideology when there is a failure of people (workers) to resist. But when activist leaders speak up they hardly receive people’s organizational support. As a result, simple patronizing by leaders is dismissed by the powers-that-be as something they can live with. Regrettably, often, unions pay much more attention to aspects of pay and working conditions thus becoming increasingly inward looking; this shows that market ideology has reached deep into the labor movement.
The prison of current global governance regimes:
-In the face of increasingly undemocratic governance, health professionals, alongside public interest civil society, need to be prepared to confront power.
-A purely institutional view of global health governance is a race to the bottom; it does not help confront the global health crisis rooted in the global neoliberal economic system.
8. The aim is to turn growing public dissatisfaction to a movement that challenges the Establishment. History is replete with examples of the failure of professionals to challenge or resist egregious policies to the detriment ofall concerned and of their HR.****
****: Note that the right to health, as well as the notions of equality, universalism and solidarity have different meanings according to who uses them. We are then left playing a role in a battle over true meaning in a sort of ideological warfare. Written protests over the misuse of these terms by those who favor the status-quo have been mostly relegated to the grey literature.
9. A final note here: The WHO we need to firmly take up global governance in health as per its constitutional mandate will not emerge from the current reform process under way. But it would be a serious mistake to write WHO off as an institutional failure.
The prison of official development assistance (ODA)
10. To begin with, addressing development as something that refers only to underdeveloped countries, invariably presents development as a process to be mediated by charitable-giving-as-development-assistance.
11. ODA legitimizes the global and national governance structures, because it is not accompanied by structural changes in global finance, trade and investment.
12. The dependency that ODA creates redirects accountability away from being accountable to grassroots constituencies towards being accountable to funders and corporations.
[Muchhas been said in these Readers aboutforeign aid so no more details will be brought up here. See Human Rights Readers 120, 202 and 358].
The prison of the neoliberal welfare state
13. Social protection systems in the welfare state exemplify several features of the neoliberal approach to development, one that individualizes problems and their solutions and frees governments from promoting the collective welfare of their citizens.
14. As set, ‘social protection floors’ suffer from serious flaws. They do not strive for universalism or a shift away from neoliberalism. They do not seek redistribution of wealth; they propose no changesin the prevailing economic paradigm; they do not shift away from productivism and perpetuate a growth orientation model despite well-known grave environmental constraints. Little surprise then that social protection schemes do not automatically bring about political, economic and social change.
15. Let’s face it, poverty reduction policies have never been really meant to implement fair social protection floors, but have been an alternative to it. In a nutshell, these policies have nothing to do with disparity reduction, i.e., a correction of the negative processes and outcomes of neoliberal policies.
A couple ways of breaking out of the prison:
The indispensable role of community health workers
16. Health is created before and beyond the health system. It is nested in the social conditions in which we grow up, live, learn, work and play.
17. This is the reason why community health workers (CHWs) must have a dual role as providers of basic services and as agents of social mobilization. They are much more than ‘task shifting agents’ (in a shift away from formally trained health professionals*****) and do work wellgiven adequate support supervision. CHWs have a dual accountability: to health sector authorities and to their communities. They cannot be deployed as single-purpose-workers, but rather as ‘community care givers’. They should thus not be seen as health providers, but as community representatives. Activism and leadership should be part of their training so they can tackle the social determination of health, as well as tackle urgent environmental issues. Their role is to contribute to a fair distribution of health resources and ultimately of power. In short, they are not in the business of treating diseases, but rather in the business of promoting community health.
*****: Much of it as a result of the ongoing brain drain: It is time to re-politicize the discussion to address the brain drain/brain robbery issue!
18. The (not so) new thinking about CHWs is them beingproviders of first contact care including treatment and referrals,plus addressing the broader social and environmental issues including advocacy and social mobilization,plus engaging communities in action concerning their health situation by addressing its causes, including structural causes.
NGOs versus pubic interest civil society
19. These days, traditional NGOs (especially international) are drawing local partner social groups and their activism into the safe professionalized and often depoliticized world of development practice. This often means their evolving into mere service providers or single-issue lobbyists. It also means their shifting from providing more critical to increasingly providing technical, apolitical skills over activism and proactive community engagement. In short here, this marks a departure from their traditional previous watchdog role.
20. On the other hand, more and more, public interest civil society groups are not so much about the particular actors in them but, more and more, about opening new spaces, spaces where their points of view are directed towards influencing the political discourse. Yes, so far, they often do this in isolation. But it is becoming clearer an clearer to these organizations that there are strengths joining together in a loose network of organizations and individuals to come together on one-issue-at-a-time to increasingly engage the state on structural issues.
21. Then, there is the criticism that such an engagement can eventually serve only to legitimize a fundamentally anti-poor state that gets away with yielding a-little-bit-at-a-time. So the strategic question is how to most effectively negotiate with ‘the system’ for changes-beyond-small-changes in a way that joint actions take us towards the long-term goal rather than diluting the end vision itself. In this context, PHM asks: Must civil society restrict itself to engaging in a slowly progressive dialogue when such becomes an option or must it combine it with a more confrontational approach?******
******: The principles of democracyand the dialogue that ought to go with it are poorly realized in the modern nation state; there is only a rhetorical commitment to democracyan dialoguing –and this is dangerous… and perhaps the reason for the need of a dose of confrontation…
Shifting the paradigm to a human rights paradigm
22. To take just one example, there is a dearth of mechanisms for patients, especially women and children, to demand their right to health and to nutrition (i.e., access-to and results). Much of what we see is victim blaming: “It is their fault, because of…blablabla”. But be warned: the basic underlying health issue here is a total lack of a state-supported equality response in the spirit of HR–a commitment UN member states undertook when solemnly ratifying the respective UN covenants.
23. There must thus be constant pressure and mobilization to demand the fulfillmentof these rights. Initially, we have to start by fighting for what is legitimately due to the people given their inalienable rights –even if it provides only temporary reprieve.
24. Campaigns in this area must develop resource materials for grassroots organizations in the form of pamphlets, primers, booklets; all generating evidence, from the field, on the status of violations of HR in general, and the right to health and to nutrition more specifically. This ought to lead to public action in the form of protest demonstrations, rallies, public hearings, sit-ins, as well as advocating with the media, with academics, with politicians and with parliamentarians on existing and needed policies and legislation.
25. And, to end, a not-so-facetious caveat: With a predominantly corporate-controlled media and an apathetic middle class, it has been demonstrated that a large number of people on the streets protesting against HR violations do make headlines –but only for the traffic jams they cause…sad, no?
Claudio Schuftan, Ho Chi Minh City
schuftan@phmovement.org