PHA-Exch> Food for a constitutionally mandated thought

[Claudio Schuftan]

Human Rights Reader 204



*THE PREAMBLE OF WHO'S CONSTITUTION UNEQUIVOCALLY STATES THAT THE ENJOYMENT
OF THE HIGHEST ATTAINABLE STANDARD OF HEALTH IS ONE OF THE FUNDAMENTAL
RIGHTS OF EVERY HUMAN BEING: IS WHO LIVING UP TO ITS MANDATE?*



1. Weak health systems are infringing the human rights (HR) of both patients
*and* health workers. Therefore, and because they are not currently doing
so, health systems are to be reorganized to give social action and
empowerment greater preeminence*: That is where I see one of the key
challenges lies for WHO.

___________

*: We here understand empowerment as a concept that challenges established
hegemonies and bases itself in the human rights discourse. Empowerment is
not just about knowledge; it is about the recognition and the building of
abilities to change power relations in society. Outside agencies cannot and
do not empower anybody; they may facilitate, but ultimately it is the people
who wrest power and thus need to empower themselves. Empowerment to achieve
development (and health) means changing the causes of inequity, changing
economic relations, changing conditions of work and of living, and securing
access to resources so as to change the power relations that determine
preventable ill-health, and malnutrition, as well as excess deaths. Even in
a remote village or a slum, the struggles for development, for health and
for social justice, are inseparable from the global struggle for a more just
world economic and social order. (A. Sengupta)



2. A sample of just four symptoms of where the health systems have gone
wrong (mostly following WB-sponsored and WHO-condoned health system reforms
--which will be covered in the next two HR Readers) is as follows:



i) We are all aware of the ever shrinking budgets for the public health
sector in most poor countries. Add to this the South-North brain drain of
health personnel which is catastrophically affecting the availability and
quality of health services in many of those poor countries. [And this, while
health tourism is flourishing in some of the countries with huge disparities
in access to health; health tourism is creating important islands of
internal brain drain from the public to the for-profit private sector and is
draining scarce resources for health within those countries].



ii) The health systems required to deliver the needed prevention and care
for AIDS are more than weak in the most affected countries --a fact that was
overlooked for over a decade. Moreover, AIDS is not only receiving the
lion's share of international aid (with all the distortions this brings to
the health sector), but AIDS is now increasingly being considered an
opportunistic disease in poor people. *[So, how much is WHO, in concert with
other agencies, doing about poverty…?].*



iii) WHO is party to dozens of public-private partnerships, many of which
have perpetuated vertical approaches to mostly single disease control
strategies. *[How can this be reconciled with WHO's 2008 newly-found
(re)dedication to PHC?].*



iv) The promotion of private health insurance schemes for the middle class
has been a chronicle of hidden restrictive clauses in the small letters of
insurance policies, and of 'cherry picking' practices that reject patients
with chronic underlying conditions leaving them for the public sector to
deal with. On the other hand, although community-based health insurance
schemes have been hailed as a health care financing breakthrough, it
actually pools premia only from the poor themselves. This clearly betrays
the solidarity principle of cross-subsidies that any equitable insurance
system should bring about. Not engaging such solidarity mechanisms results
in segmentation in the provision of health care services.**

________________

**: To explain the latter, let me bring up a metaphorical example of a lunch
party in a pricy restaurant: Three persons are invited. One is able to pay
in full and gets a sumptuous menu; another can only afford half the cost and
gets a poor menu; the third person, who cannot pay, gets bread and water.
The three can say they attended the lunch at this expensive restaurant --but
they are not treated equally… Insurance schemes for the poor mostly offer
minimum/basic packages of health care. All invited must have the right to
the same meal! (i.e., vaccines yes, but cancer drugs no??). (A. Denegri)



3. The quest for health equity is often rightfully used as the major
argument against privatization and for greater government involvement in
health care. But WB-sponsored and WHO-condoned health system reforms have
kept pushing for the elusive and unattainable principle of "those who can
pay should pay". Nothing terribly wrong with this. However, we are told that
private outlets are the best suited to apply the principle… This, despite
the fact that case after case has shown that poor populations are
consistently left behind and out in initiatives that try to apply that
principle.



4. The question in all the above is: How is all this compatible with WHO's
Constitution and thus with its mandate? It is true WHO is, in a targeted
way, active in some of these areas: sometimes taking a position compatible,
sometimes incompatible with the HR-based framework that should rule over all
its actions. An inconsistency clearly exists.



5. The HR framework stands squarely against the push for privatization and
against considering investments in health as a means to increase
productivity and to support the 'global security' discourse in relation to
development assistance in health --as the Macroeconomics and Health (Sachs)
Report clearly did in 2001.



6. There is no way around for WHO: Health must be defined as a fundamental
HR (we note here that there is no such a thing as a basic HR! all human
rights are basic). This is of crucial importance as the HR framework is
entirely different to the Basic Needs Approach in shaping the entire manner
in which *all* needed measures must be taken to meet the health needs of all
(and we are all born with this right). Health is a public good; and this
means that people's health is not just another good that can be left to
market forces.



7. This also has profound implications in the need to change the curricula
of health (and nutrition) professionals' training programs so that they more
decisively emphasize the  HR-based framework, as well as public health and
public nutrition. The current system of training future colleagues has yet
to be replaced, and this is clearly another area WHO should be more active
in. There has been a long discussion whether we are training activists or
'engineers' that apply mainly technical measures. Mostly engineers are being
trained/produced (A. Berg). In the last decades, engineers have not
succeeded in solving the big health and nutrition problems; faculty members
of training institutions have not been commensurately retrained; and
students and alumnae have not been involved in discussions to push for the
curricular changes needed. The 'engineer-activists' we really need are not
being produced, those who understand the HR, social and political
determinants of preventable ill-health, malnutrition and excess deaths --as
well as become involved in the more structural measures needed to overcome
them. *[Ergo, should we be surprised of the ongoing status quo? Or more
importantly, what should WHO be doing in this realm?].*



8. *So what next?:*

Can WHO be the engine of change to overturn these realities? It has to!

How is it to interact in a new way with member states (and universities for
the training aspects) who are the ones that must ultimately do the
overturning? *[WHO simply has to find the ways, now!].* ***

________

***: WHO's Commission on the Social Determinants of Health and the
PHM/MEDACT *Global Watch II* (2008) point towards viable alternatives. (
www.phmovement.org) WHO is urgently called upon to incorporate these --and
for this it will have to undergo serious restructuring.



9. Finally, one cannot but ask the question:  Is all that needs to be done
too expensive to do? … or will it be more expensive not to do anything? I am
afraid we have not even yet reached the point where the central question is
one of money…we are even before that stage. How I wish I were wrong…



Claudio Schuftan, Ho Chi Minh City

cschuftan at phmovement.org

[All Readers can be found in www.humaninfo.org/aviva  under No.
69<http://www.humaninfo.org/aviva%20%20under%20No.%2069>
]
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