PHA-Exchange> Food for excessively medicalized thoughts

[claudio]

Human Rights Reader 45

GLOBALIZATION, HEALTH RIGHTS AND HEALTH SECTOR REFORM: IMPLICATION FOR
FUTURE HEALTH POLICY:


1. In most of the world, Health Sector Reforms (HSR) are sick.
They are terminally ill --in part due to the Negative Consequences of
Globalization (G) on the right to health. So we better recognize its
symptoms.
Denial of the symptoms may be a good temporary defense. But only until
reality imposes itself on us.

2. This reality is that we have been giving technical solutions to what are
political and human rights problems. Ergo, we cannot medicalize HSR any
longer!

3. 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...

4. 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.

5. Around the world, what the poor people to be served by true HSR want is
simply more: more justice for their entitlements, more from health, more
from life, more from history, and more from us!

6. Hereunder are about fifty 'bullets'; they are in no particular order, but
are just primers for you to use to start a meaningful debate on this issue.

i-The structural reforms that come with Globalization have negatively
affected the most vulnerable segments of society; also, income distribution
and economic access to health have become much more unequal.

ii-Civil society needs to become more organized to challenge the power of
the states that foster or go along with Globalization and progressively
neglect their human rights responsibilities in health.

iii-Civil society needs to increasingly be visible as a credible negotiator
between the people and public powers. It has to become a watchdog to contain
market and Globalization excesses. They also have to raise the awareness of
the people re the challenges Globalization poses. (Best example: the
worldwide People's Health Movement and the Politics of Health website).
(www.phmovement.org ) (www.politicsofhealth.org )

iv-The short-run effects of Globalization on the poor ARE negative and
significant... So, compensatory policies are being promoted and designed to
help the poor to deal with, for example, falling health standards. But this
is reactive/palliative and not proactive/preventive...).

v-What are needed are pro-poor/pro-human rights budgets and growth
strategies; policies geared towards ensuring that people receive adequate
food, education and health care; broad participation in policy design and
implementation; environmental and social awareness; and efforts to combat
discrimination:
'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-Pro-poor structural reforms we so much talk about are yet off-limits for
the macro policy establishment. At the macro level, 'the social' continues
to be an afterthought. But macroeconomic policies should add on to social
policies if they are to achieve poverty 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 achieve acceptable outcomes.

ix-The social exclusion inherent in neoliberal growth models should simply
be rejected. We should accept nothing less than social inclusion of the
poor.

x-With Globalization, the trend is thus toward a drastic reduction of
state-based entitlements and their replacement by market-based,
individualized entitlements... But the invisible hand of the market has no
capacity 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 hunger, famine and ill-health.

xi-Moreover, with Globalization, priority is granted to efficiency over
other values such as social justice or environmental sustainability.

xii-We 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 redistribution and equity... The
idea that any pivatization is better than no privatization should be
rejected.

xiv-In sum, the negative effects of Globalization are reversing some of the
social gains already made; it is lessening the likelihood that developing
countries will have the necessary policy autonomy and fiscal capacity to
carry out and finance comprehensive health policies.

xv-Although NGOs have enjoyed a high profile in recent years they have
mostly remained in the reactive mode. There are signals that their heyday is
over. Many stand accused of complacency and self-interest on the one hand,
and of being ineffectual and irrelevant on the other.

xvi-Globalization has brought about a shift in power: the nation state has
weakened and there is a reduction in social accountability. Moreover, '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.

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 daily.

xviii-Governments in the Third World are simply assumed 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 the poor and end up widening the gap between the
rich and poor.

xix-Under Globalization, the annual losses to developing countries run at an
estimated $500 billion --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 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 underlying more structural 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 targeting of subsidies (i.e. selective subsidies of
goods and services disproportionately consumed by the poor), prepayment
plans (e.g. community-based health insurance), exemptions and the selective
dropping of some fees (e.g. health and educational), prevention and on
improvements of the quality of care (in health), as well as on a fairer
urban/rural distribution of resources.

xxiii-Expenditures on health have to increase, they say, but to be
equitable, they have to be concentrated on preventive activities in rural
areas and should be targeted to the lower income quintile.

xxiv-Globalization may be inevitable, but what it looks like is not --there
are forces that can shape it, and human rights 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. Bolder steps will have to follow.

xxvi-Furthermore, we have to fight the indifference of our youth to the
present global situation: our young and upcoming colleagues. We have thus to
enroll the youth before they resign themselves... Our youth seems more
interested in the information superhighway.

xxvii- In sum, an effective challenge against Globalization and its negative
effects on health is possible, but demands the same kind of intellectual
commitment and vigor that characterized anti-colonial or independence
struggles.

xxviii-Western intellectuals have simply abandoned their commitment to
challenge the exploitation and oppression of the poor 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 our youth and of ourselves.

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 fall outside the ruling paradigm.

xxx-Development cooperation must thus become more political and more human
rights oriented, because only 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 ill-health
and malnutrition in the world.

xxxii-But the inertia is so great and our collective virtual view of reality
so distorted and entrenched, in part due to Globalization, that the
likelihood of us changing that reality remains dim.

xxxiii-In short, we need to give a larger intellectual and political scope
to our discussions on Globalization.  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/pro-poor/pro-women/pro-human rights based strategies on the
highest of moral grounds.

xxxvi-Globalization does not have a human face; power differentials are at
its crux. It is a process we cannot wish away.

xxxvii-When government expenditures in health in developing countries are
shrinking, the World Bank has them pushing for a greater role of market
forces in the production and distribution of health.

xxxviii-Providing health care as a human right and on the basis of need is
being replaced by a system based on cost recovery where exemptions for the
poor have not worked.

xxxix-Safety nets are nothing but a way to manage poverty attenuating social
unrest.

xxxx-The politics of health will override all other efforts to bring us
Health for All. (Equity is the forgotten key thrust of Alma Ata!...this year
in its 25th anniversary!). A renewed commitment and resolve to foster
empowering community-based activities will have to guide our actions.

xxxxi- 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 HSRs measures are
actually Structural Adjustment measures in disguise.

xxxxii-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!

xxxxiii-Evidence that market-oriented health care systems are more efficient
are not really well founded (look at the USA.); they are just more
profitable to some and too often provide unnecessary care.

xxxxiv-Conversely, evidence that public health care systems are more
equity-oriented and can be made more efficient, does exist.

xxxxv-The cost recovery system is a regressive tax in which the poor pay as
much as the non-poor; becoming sick thus penalizes the poor more, and high
fees for health care are a major cause of pauperization.

xxxxvi-Direct and indirect progressive taxes (and non-private insurance
schemes) must thus constitute the financial basis in an equity-oriented
health care system.

xxxxvii-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).

xxxxviii-Another perennial problem of HSRs is that decision-making has
allowed limited involvement of the beneficiaries themselves.

xxxxix-Bottom line, HSRs 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.

L-HSRs alone cannot simply address the human rights and structural
constraints to equitable health, not even with good targeting.

Li-Tinkering with the current HSR models will simply not do. This is the sad
reality. Precious time is likely to be lost only to see the problems of
inequity worsen.and what is inequitable today will be inhuman tomorrow.

Lii-So what would be more effective and sustainable?
a) First, it is not for us in this distinguished virtual gathering to come
up with the responses.
b) For once, it would be best to ask the beneficiaries directly to respond
to this question rather than coming up with some technical responses.
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
beneficiaries.
d) The bottom line is that --together with the beneficiaries-- we need to
articulate a more sustainable Equity-Oriented Health Sector Reform (EOHSR).

Liii-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!

Liv-Contradictions between ministries of health and the people they say they
serve have not changed a bit with the (often foreign-driven) HSR as applied
in many countries worldwide.

Lv-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.

Lvi-We need to get involved with beneficiaries in consciousness raising,
increasing their rights awareness and their political awareness of why they
are where they are.

Lvii-In short, what is needed now is a start-over, a global movement, a
grassroots revolution around the right to health.

Claudio Schuftan, Ho Chi Minh City
aviva at netnam.vn