PHA-Exchange> food for a dialectical thought

[Aviva]

'ELEMENTAL WATSON: THE HEALTH SECTOR REFORM'S FAULTY LOGIC.

-? 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.phamovement.org .

-? In short: What is needed now is a start-over, a movement, a grassroots
revolution in health.

-? 'Elemental Watson'!

Claudio Schuftan, Hanoi
aviva at netnam.vn