PHM-Exch> Rép. : Donors urged to tackle leading killer of under-fives (2)

[Slim SLAMA]

Interesting and important debate, indeed. I see that after having played
a leading role in the evolution of health promotion, Canada seems to
take the lead in this discussion.

Commenting on the last post from Ronald Labonte: "we must always try to
frame our health arguments around the historic and contemporary
practices of power and privilege that allocate wealth and health to
some, and poverty and disease to others. Regardless of disease."

To understand comtemporary practises, it is interesting to look at how
major donor countries have themselves engaged into the debate in their
own countries. Currently doing my MSc in Public Health at LSHTM, I have
the opportunity to better understand how the recent neoliberal reforms
within the NHS have contributed to reshape the debate both locally and
abroad. The important point of entry is what Ted Schreker' refered to as
the  "scarcity rhethoric".

In UK, since the Griffith report and the adoption of the 'new public
management' within the NHS, the current debate pretty much focuses on
priority setting (or more emotionally worded) rationing, assuming that
resources are "naturally" finite and scarce. Having set these
boundaries, the debate moves then to discuss whether rationing should be
made explicit or not. Whether resource scarcities could result from
policy choices or other unfair social arrangements doesn't enter the
equation.
Instead of challenging the policy choices that were responsible of this
unbalanced distribution, many public health practitioners concentrate
their analysis on how to establish a  fair process for priority setting
(what Norman Daniels and Jim Sabin have called "The accountability for
reasonableness" (BMJ 2000;321(7272):1300 (25 November), doi:10.1136)

More worrisome, frontline workers, PCT directors  and communities finish
to bargain within this given framework, negotiating access at the
margins rather than struggling for more resources according to their
needs.

The call for rationality and objective assessment through the creation
of specific commissions or institutes (NICE) doesn't  seem to have
resolved the ethical dilemma. The last avatar of these reforms, The
World Class Commissioning (new form of commissioning health services in
UK)
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085148)
will not change anything to the problem. 
A sobering situation shared by many OECD countries that tend to export
their problems when dealing with resource allocation issues.

Slim Slama
MD, International and Humanitarian Division, University Hospital of
Geneva
Geneva Health Forum Programme Director - www.genevahealthforum.org


>>> Claudio Schuftan <cschuftan at phmovement.org> 17/05/09 20:28 >>>
 1.

We need to all join together and stand strongly against DIVISION of
health issues that are in reality both a right and indivisible one from
another...

One cannot have PHC without massive health work force investments,
and changes in IFI policy.

We need to grow a global movement for health care as a right...
We are meeting to discuss it...want to include all of
you and more

Joia S. Mukherjee, MD, MPH
Medical Director, Partners In Health

2.

I find this disturbing because the message that this sends in my view
is - AIDS, TB and malaria is getting too much money so let's move some
of it to address diarrheal diseases. It is true that AIDS has received
relatively more money than other health issues, but should we be
promoting what I interpret as the key msg in the articles the notion
that shifting money from one disease to another is the answer? This is
exactly the kind of divisive rhetoric that we should be resisting. So
we should move money away from AIDS, TB and malaria to focus on saving
children from diarrheal disease? You save a child's life from
diarrheal disease, but then the child dies of malaria because now the
pendulum of resources has swung the other way? We need to be working
towards messages of increasing money for everythindisease against disease, MDG against MDG and ultimately trading
deaths. I find this really not helpful.

Sue Perez

3.

I share Sue Perez's misgivings.  Claims that "too much" is being spent
on
AIDS, or any other health issue, are the unfortunate but inevitable
result
of counting DALYs and taking at face value the rhetoric of "scarce
resources."  As we know from recent experience, resources are not scarce
when needed to bail out mismanaged financial institutions ... and they
are
never scarce for war-fighting.  Self-promotion it may be, but see my
article
on this point at http://www.who.int/bulletin/volumes/86/8/08-050880.pdf.

Ted Schrecker



 4.

I agree with Sue's concern. I would also note that the actual reports
are
calling for 'a comparable effort' to HIV for funding for diarrheal
diseases,
not a trade-off.

The securitization of HIV (and pandemic influenza, the other massively
funded global disease) in UN resolutions; the prevalence of one and the
threat of the other in donor countries; and the existence of strong
civil
society advocacy groups for one and a public health community for the
other
created the momentum for public funding vastly disproportionate to
funding
for other diseases. Understanding the history of how health funding
became
skewed in this fashion is important if we are to develop strategies to
argue
for needs-based alternatives which do not mean reducing funds for one to
compensate for lack of funds for another. That chronic disease has
supplanted communicable disease in all parts of the world except
sub-Saharan
Africa (and receives virtually no donor funding) is slowly becoming a
higher-order topic of global health concern.

Unfortunately, HIV funding is the comparative lightening rod: witness
the
recent World Bank internal evaluation report that found that as HIV
funding
increased, consuming almost all of the resources for communicable
diseases,
funding for family planning and reproductive health plummeted. Donor
agencies are triaging their resources in disease-specific ways that do
not
reflect overall disease burdens.

To prevent the trading-off of one disease over another, we need, first,
to
support the funding claims made by other groups -- in this case,
agreeing
absolutely with the 'comparable effort' argument around water,
sanitation
and diarrheal diseases in the two NGOs reports. Second, we can cite the
economic arguments and cost studies abound that show the affordability
of
both and, as Ted has just posted, that decisions on where and how to
invest
collective wealth is a matter of politics and policy, not of scarcity.
Third, we can argue that human rights treaties oblige wealthier nations
to
assist.

Finally, we must always try to frame our health arguments around the
historic and contemporary practices of power and privilege that allocate
wealth and health to some, and poverty and disease to others. Regardless
of
disease.

Ronald Labonté
Canada Research Chair, Globalization/Health Equity