PHM-Exch> Food for a thought to watch

[Claudio Schuftan]

Human Rights Reader 291



*WHAT CAN WE DO TO INTENTIONALLY SHAPE OUR COLLECTIVE DESTINY? *(part 1 of
2)

* *

[The following two Readers are a summarization of the key messages found in
Global Health Watch 3, PHM’s alternative flagship publication that analyzes
the current world health situation].



1. Our collective destiny is not in our hands. It is in the hands of a
handful of powerful agencies over which we have no control. It is our
respective governments that appoint the country’s representatives to these
international decision-making bodies (which often do not even have a
‘one-country-one-vote’ modus operandus). Each government instructs their
reps on the position they should take (very rarely pertaining to human
rights issues), the tactics they should use and the votes they should cast;
and it is each government that is empowered to remove them should they fail
to fulfill their responsibilities.



2. Since electorates typically have almost nil influence in this
international decision-making --while the corporate sector has much
stronger and more direct interests-- the agenda of international
organizations is increasingly skewed strongly in favor of corporate
interests which reflect only a window-dressing-interest in human rights
(HR).



3. Moreover, since the proceedings of the WB and IMF Boards, for example,
are confidential, this means that only governments know their votes were
affectively used, allowing them to operate with zero accountability to
their electorates for the positions they take. These interests, which too
often regrettably clash with human rights (HR), are nationalistic in
nature, primarily promoting national commercial and financial interests and
pursue geopolitical and ideological agendas. This, rather than seeking the
greater common good, in our case HR. It is nor surprise, then, that this
results in a *system oriented to the promotion of the interests of the rich*
.*

*: Very few people do the following calculations. But be educated: To
double the income of the poorer 10% of the world’s population without any
redistribution of income would require 100% economic growth, i.e., doubling
global production and consumption and dealing with the catastrophic
associated environmental costs. At a growth rate of the GNP of 3% per year
the process would take 24 years. Alternatively, the same result could be
achieved immediately by redistributing less than 1/3 of 1% of the income
from the richest 10% of the world’s population to the poorest 10%. Does
this tell us something?



4. As regards WTO agreements, the same end up being given precedence over
other agreements, including those directed towards protecting human rights
or achieving social and/or environmental goals. Under such constraints, policy
makers in health become ‘policy-takers’ who must adapt to the effects of
trade agreements, i.e., ultimately, health policy ends up being made to fit
trade agreements which is nonsensical.



*A crisis of capitalism?*

5. We have so many times said that people in the North desperately need to
take responsibility for their historical and present contributions to
climate change. But it actually also is the whole process of Globalization
that is, in good measure, responsible for the climate crisis. Why? Because
the climate crisis is a crisis of over-consumption; conversely, the
development crisis is a crisis of under-consumption! As you know,
Globalization creates powerful emerging markets *and* --let us not
overlook-- *sub*merging markets that struggle to keep their heads above
water as the rising tide of global economic growth conspicuously fails to
lift all boats. This results in the fact that it is income and wealth that
are, these days more than ever, the fundamental determinants of social
status and self worth. Increasingly, the financial tail is wagging the
economic, social and political dog. The overall and HR disaster this
creates is now history.



6. For too many decades, the global economic system is grounded firmly on
capitalist principles, on booms and busts. The most recent financial crisis
has clearly demonstrated its failure either to satisfy the most basic needs
of most of humanity or to operate within the confines of environmental
sustainability.



7. The current crisis of the global economy is actually systemic and
demonstrates the non-viability of capitalism in its current form,
characterized as it is by extreme inequality, HR violations and poorly
regulated markets, as well as dominated by the interests of a small rich
minority embedded in the corporate and financial sectors.



8. If we want to achieve social and HR goals such as health for all,
poverty eradication, universal education… i.e., the fulfillment of human
potential --and to do so while simultaneously tackling climate change and
achieving true environmental sustainability-- then we need to redesign the
global economic system to realize these aims. We cannot simply assume that
these goals will somehow magically be achieved under an economic model
designed to achieve fundamentally different and, in many respects,
contradictory goals. The maximization of production and of consumption
--implemented through grossly undemocratic decision-making processes in the
interests of those with the greatest power and the greatest resources--
spells disaster.



9. Like it or not, this is what has brought us to the current situation,
one that is characterized by multiple crises. We cannot realistically
expect more of the same to get us out of it.



*Repercussions on Primary Health Care*

10. Although several global health initiatives have brought welcome
increased funding for priority diseases, they have at the same time
reinforced the selective approach to health care by privileging vertically
implemented and managed programs that mainly emphasize therapeutic and
personal preventive interventions while significantly neglecting upstream
determinants of these diseases, i.e., we are (and have been) faced with a
phasing-in of a broad set of selective interventions at the expense of a
comprehensive primary health care (PHC) approach.



11. Historically, we know that significant health improvements firmly
rooted in PHC only began to appear when the increasing political voice and
self-organization of the growing urban masses finally made itself heard.**
Why? Because the rich end up benefiting most when a major share of tax
funding is allocated to larger, expensive, urban-based hospitals rather
than to PHC* services both in urban and in rural areas*.

**: For long now, the People’s Health Movement has been saying that health
is a political, a HR, as well as a technical subject. It has, therefore,
been calling on WHO to accept the responsibility of engaging in the
politics of health, as well as advising on technical issues.



12. A strong, organized demand for government responsiveness and
accountability to social and HR needs is thus crucial to secure pro-PHC
public policies. A process of social mobilization involving broad sectors
of civil society, which may take different forms in different contexts, is
essential to achieve and sustain such a political will for a genuine PHC.



*Repercussions on health care financing*

13. Today, the potential for agreement among rich countries in pushing
disease-centered health outcomes is much greater than the potential for
them agreeing to help finance health-for-all strategies and more equitable
income distribution strategies. It is clearly ideology that is getting in
the way of finding progressive solutions.



14. We already know that user fees at the point of service prioritize
efficiency over equity. As the evidence demonstrates, in practice, user
fees for health services are both inefficient, regressive and against the
grain of the human right to health concept. While the academic argument on
this has been won, the practical implementation of universal access,
tax-based-free-care-at-the-point-of-use is proving to be ­the barrier we
all should get involved-in as a matter of priority. **** What matters most
in health care financing today is reaching universal coverage in as many
countries as possible. For this, the size of the pool remains the key
factor in any insurance scheme. The argument goes like this: The greater
the risks ***** and the larger the resources pooled together, the wider the
coverage, the greater the financial protection, and the greater the chances
of achieving* financial sustainability*.

****: Is community-based health insurance an alternative? Contended issue.
Why? Because the poorer are much less likely to join a scheme like this if
premia are not subsidized. Hence community-based health insurance
definitely requires support from the central government. Varied mechanisms
to ensure sustainability of such schemes have been attempted in numerous
countries, but have often conflicted with equity concerns, i.e., they
stubbornly exclude high-risk individuals from membership, this affecting
the sickest and the most vulnerable members of the population. Otherwise,
increasing premium levels will discourage the poor from joining. Otherwise,
placing limitations on benefit packages may enable better financial
sustainability, but will limit the attractiveness of the scheme (Bennett et
al. 2004). Overall, community-based health insurance offers only a marginal
improvement over user fees. It is no panacea.

*****: Note that traditional public health and actuarial research uses
a *risk-factor
*approach; such an approach fails to reveal multi-causal mechanisms and to
reveal the root causes of health inequities.



15. At the end of the day, it is the relationship between the state and
society (their social contract) that will determine the feasibility of
implementing a fully tax-based system. Tax compliance is based on an
‘understanding’ between the government and its people. Since most taxes are
collected where there is primarily voluntary compliance, the collection of
taxes requires substantial coercive power *and* for the state to be
legitimate. No country, no matter how rich, has sufficient resources for
penalizing all those who do not respect the tax laws.



16. The level of social cohesion across socio-economic groups is also an
important constraint to the successful implementation of tax-based health
care financing schemes, particularly in countries with high levels of
income inequality where the rich may feel that they pay too much to
subsidize others. Taxation and tax reform are central to state building.



17.If the above is somehow resolved, the biggest concern that still remains
is how to extend coverage beyond the formal sector and without
discriminations of any kind. (We are aware of the persistent failure to tax
the informal sector… but beware: Informal does not mean poor).



*Repercussions on maternal mortality*

18. Human rights treaties and conventions do not include an explicit right
to women’s health. But failure to address the preventable causes of
maternal death is a violation of women’s human rights, for which states can
be held accountable. (HR Council resolution in 2010)



19. It is important to highlight the fact that social injustices contribute
to avoidable maternal deaths. As you know already, once an issue is
recognized as a human right, there is a legal obligation to take steps that
are deliberate, concrete and targeted towards the realization of the right.
This, then. underlines the importance of the paradigm shift needed in local
heath systems policies.



20. Furthermore, the life-cycle approach preferred by several new-age
maternal health rights proponents continues to identify reproduction as *the
* criterion for defining the stages of life. This strategy leads to simply
further medicalizing reproduction and neglecting the rights of women with
little attention being paid to local needs and social realities.



21. In short, maternal health needs need to be addressed within the larger
framework of collapsing health systems. It is thus a fallacy to consider
the number of institutional deliveries a proxy for better maternal health
care.



Claudio Schuftan

cschuftan at phmovement.org  <cschuftan at phmovement.org> **

*____________________*

Summarized and adapted from Global Health Watch 3, An Alternative World
Health Report. People’s Health Movement, Zed Books, London and New York,
October 2011.  www.ghwatch.org/ghw3*  ***
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