· 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.
· They further claim the stimuli for these reforms come (came) from the stakeholders themselves.
· Nothing could be further away from the truth.
· Contradictions between ministries of health and the people they purport to serve have not changed a bit with the (often foreign-driven) health sector reform applied in many countries worldwide.
· An elemental dialectical analysis of the situation would bring this clearly to the fore.
· We do not think dialectically anymore; dialectics is supposed to have died with the demise of communism in the Soviet Union.
· But dialectics is independent of communism; it is an analytical tool that brings out the contradictions among social classes in a given society….and the health sector is a sector that badly needs to be looked at dialectically if we are ever to solve its growing problems.
· Issues of power and control are (and have always been) behind the state of affairs we see right now.
· Who wins/who loses? What? How? Through what mechanisms? and Why? – these are the kind of questions we are not asking.
· We need to bring such an analysis of dialectical relations in health to a level field – away from the current (im)balance heavily tilted towards the haves and with outcomes (and inputs) that are mostly controlled by them.
· Why? Because no social progress has ever come from the benevolence of the haves.
· Only once we move our analysis back to dialectics, will we realize that we are facing an unbalanced relationship: opposing factions that are supposed to be involved in a struggle, are not engaged in a real struggle right now.
· There is no real de-facto opposition from the users/beneficiaries to the policies imposed on them from above (and from foreign lands and/or international institutions at that).
· So, what is needed to get back on track for a dialectical analysis and actions consequent with it?
· We need to get involved with beneficiaries in consciousness raising, 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 and keep asking “yes, but why that? to their responses until they get to the determining basic, structural and underlying power issues).
· We have to open up the dialogue towards topics like:
· equity,
· health as a human right,
· effective decentralization and devolution of power (democratization) [the latter two already called for by the Alma Ata Declaration…],
· the role of Globalization on the current state of affairs in health,
· the role of international financial institutions (WB/IMF), and
· the role of donors, the UN system and NGOs.
· And more technically, cover topics such as:
· the fee for service system,
· social health insurance,
· local health systems development,
· essential drugs,
· community-managed health programs and co-management of health facilities, and
· joint-decision making.
· These are just some of the tactics to follow to more proactively engage in balancing the dialectical struggle in the health sector.
· More elements to use in the struggle should and will come from the beneficiaries themselves.
· We should not be prescriptive, but just help open this new avenue.
· We do not even have to reinvent the wheel: see the People’s Charter for Health at www.phmovement.org
· In short: What is needed now is a start-over, a movement, a grassroots revolution in health.
· ‘Elemental Watson’!
Claudio Schuftan, Saigon
schuftan@gmail.com