Claudio Schuftan MD
cschuftan@phmovement.org
-‘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.
-Globalization does not have a human face; power differentials are at its crux. It is a process we cannot wish away.
In most of the world, Health Sector Reforms are sick.
They are terminally ill –in part due to the negative consequences of Globalization on the Human Right to Health. So we better recognize its symptoms and signs. Denial of the latter may be a good temporary defense –but only until reality imposes itself on us. This reality shows that we have been giving technical solutions to what are political and Human Rights problems. Ergo, we cannot medicalize Health Sector Reforms 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 Health Sector Reforms want is simply more: more from justice (to guarantee access to what they are entitled to), more from health, more from life, more from history, and more from us!
Hereunder are a number of ‘bullets’ that are primers for the reader to use to start a meaningful debate on the central issue of this article (they are in no particular order):
i) The structural reforms that have come with Globalization have negatively affected the most vulnerable segments of society; also, income distribution and economic access to health have become much more and increasingly unequal.
ii) Civil society needs to become more organized to challenge the power of the states that foster (or go along with) Globalization and that progressively neglect their Human Rights obligations in the area of health.
iii) Organized civil society groups need to become increasingly visible as a credible negotiators between claim holders and duty bearers in both the public and the private sector; these groups have to become watchdogs to contain the excesses of global marketization. Civil society also has to raise the awareness of claim holders in relation to the challenges Globalization poses. [The best examples are the work of the global People’s Health Movement (www.phmovement.org ) and the Politics of Health website (www.politicsofhealth.org)].
iv) The short-term effects of Globalization on poor people are indeed negative and significant… This is why compensatory (safety net type) policies are being promoted and designed to help people being rendered poor to deal with, for example, falling health standards. But these policies are reactive and palliative and do not question the structural causes of these negative effects.
v) What are needed are Human Rights-based budgets and growth strategies that address health as a right and combat discrimination; policies geared towards ensuring that people receive adequate food, education and health care, that create social and environmental awareness, and that assure broad participation in policy design and implementation. (Remember: ‘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) Poverty-alleviating (i.e., disparity-reducing) structural reforms we so much talk about are yet beyond the horizon of the macro policy establishment. At the macro level, ‘the social’ continues to be but an afterthought. As we see it, macroeconomic policies should be add-ons to social policies if they are to achieve disparity 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 minimize negative outcomes.
ix) Furthermore, the social exclusion inherent to the neoliberal growth model of Globalization must simply be rejected. Nothing less than social inclusion of those rendered poor should be accepted.
x) With Globalization, the trend is towards a drastic reduction of collective entitlements –which are the responsibility of the state– and towards their replacement by market-based, individualized entitlements. But the invisible hand of the market has nothing in it 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 preventable malnutrition, preventable ill-health and preventable deaths.
xi) Moreover, with Globalization, priority is granted to efficiency over other values such as social justice or environmental sustainability.
xii) We, therefore, 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 wealth redistribution and equity…). The idea that any privatization is better than no privatization should thus be rejected.
xiv) In sum so far, the negative effects of Globalization are reversing some of the social gains already made by people made poor by an unfair system. Globalization is lessening the likelihood that developing countries will have the necessary policy autonomy and fiscal capacity to carry out and finance comprehensive people-centered health policies.
xv) Although international NGOs have enjoyed a high profile in past years, many have mostly remained in the reactive mode. There are signals that their heyday is over. Many stand accused of complacency and of self-interest on the one hand, and of being ineffectual and irrelevant on the other.
xvi) Basically, Globalization has brought about a shift in power: the nation state has weakened and there is a reduction in social accountability.
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 by the day.
xviii) Governments in the Third World are simply thought 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 poor people and end-up widening the gap between rich and poor people.
xix) Be reminded that, under Globalization, the annual losses to developing countries exceed $500 billion USD –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 of 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 more structural underlying 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 the targeting of subsidies (i.e., selective subsidies of goods and services disproportionately consumed by poor people), prepayment plans (e.g., community-based health insurance), exemptions and the selective dropping of some fees (e.g., health and education fees), the improvements of the quality of care (in health), as well as a ‘fairer’ urban/rural distribution of resources. All of these take poverty as a fait accompli and miss implementing remedies that reduce disparity permanently.
xxiii) Expenditures on health have to increase, but to be equitable, in addition to macroeconomic changes, they have to be concentrated on primary health care, especially preventive activities in rural and minority areas and have to be targeted to the geographical areas where the lower income quintile groups live.
xxiv) Globalization may be inevitable, but the way it is acted out is not –there are forces that can shape it, and the adoption of the Human Rights-based approach 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. We will have to embark on bolder steps.
xxvi) Furthermore, we have to fight the indifference of our youth to the present global situation: i.e., our young and upcoming colleagues. We have thus to enroll the youth before they resign themselves and fall prey to the designs of Globalization. (These days, our youth seems more interested in the information superhighway…so let us meet them there).
xxvii) In sum here, an effective challenge against Globalization and its negative effects on health is possible. But it demands the same kind of intellectual commitment and vigor that characterized anti-colonial or independence struggles.
xxviii) Too many Northern intellectuals have simply abandoned their commitment to challenge the exploitation and oppression of poor people 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 ourselves and of our youth.
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 changes fall outside the ruling paradigm.
xxx) Development cooperation must thus become more political and more Human Rights oriented, because only true 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 preventable ill-health and malnutrition in the world.
xxxii) But the inertia is so great and the collective virtual view of reality instilled in us so distorted and entrenched, in good part due to Globalization, that the likelihood of us changing that reality remains dim unless we proactively work to change it.
xxxiii) In short, we need to give a larger intellectual and political scope to our discussions on Globalization and Health. 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/disparity reducing/pro-women/pro-Human
Rights-based strategies on the highest of moral grounds.
xxxvi) At a time when government expenditures in health in developing countries were/are shrinking, the World Bank had/has them pushing for a greater role of market forces in the production and distribution of health.
xxxvii) Providing health care as a Human Right and on the basis of need is being slowed by a system based on cost recovery where exemptions for the poorest have not worked.
xxxviii) Safety nets are nothing but a way to manage poverty to prevent or to attenuate social unrest.
xxxix) The politics of health will override all other efforts to bring us Health for All. (Equity is the forgotten key thrust we already had in the Alma Ata Declaration –now on its 36th anniversary!). A renewed commitment and resolve to foster empowering community-based activities will have to guide our actions.
xxxx) 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 Health Sector Reform measures are actually Structural Adjustment measures in disguise.
xxxxi) 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!
xxxxii) Evidence that market-oriented health care systems are more efficient are not really well founded (look at the United States…); they are just more profitable to some and too often, in the name of profit, provide unnecessary care.
xxxxiii) Conversely, evidence that public health care systems are more equity-oriented and can be made more efficient, does exist.
xxxxiv) The cost recovery system is a regressive tax in which poor people pay as much as non-poor people; becoming sick thus penalizes poor people more, and keep in mind that high fees for health care are a major cause of pauperization.
xxxxv) Direct and indirect progressive taxes (and non-private insurance schemes) must thus constitute the financial basis in an equity-oriented health care system.
xxxxvi) 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).
xxxxvii) Another perennial problem of Health Sector Reforms is that decision-making has allowed limited involvement of the beneficiaries themselves.
xxxxviii) Bottom line, Health Sector Reforms 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…
xxxxix) Health Sector Reform alone cannot by itself address the Human Rights and structural constraints to equitable health, not even with good geographic targeting.
L) Tinkering with the current Health Sector Reform models will simply not do. This is the sad reality. Precious time is likely to be lost only to see the problems of inequity and inequality worsen…and what is inequitable today will be inhuman tomorrow.
So what would be more effective and sustainable?
a) First, it is not for us in this distinguished readership to come up with the responses.
b) For once, it would be best to ask the claim holders directly to respond to this question rather than coming up with some technical responses from above.
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 claim holders.
d) The bottom line is that –together with them– we need to articulate a more sustainable Equality-Oriented Health Sector Reform.
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!
Contradictions between ministries of health and the people they say they serve have not changed a bit with the (often foreign-driven) Health Sector Reforms as applied in many countries worldwide.
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.
We need to get involved with claim holders in consciousness raising, in Human Rights Learning activities that increase their human rights and their political awareness of why their situation is where it is.
In short, what is needed now is a start-over, a global movement, a grassroots revolution around the human right to health.
Ho Chi Minh City, July 2014