PHM-Exch> [PHM NEWS] GHW5 serialized summary (2)

[Claudio Schuftan]

*A4. STRUCTURAL ROOTS OF MIGRATION. *(From previous week)

In many ways, the  ‘age of globalization’ and the ‘age of migration’
coincide.

Much of the progress in wealth (and in health) has been achieved at the
price of environmental destruction and climate change; and the health of
people cannot be seen as separate from the health of the planet as a whole.
The major crises we are facing are of our own making –-and the consequences
are well known, not only in Europe.



For 6 weeks, the PHM-exchange will, on a weekly basis, bring you summaries
of all the chapters of its recently published Global Health Watch 5.   By
the time the last installment is sent out, PHM expects to be able to post
the full text of GHW5 electronically for your reading and perusal.
We encourage you to read, use and share this material since it provides
crucial advocacy contents.


*As in the case of all previous Global Health Watches, GHW5 does nothing
but build on PHM’s People’s Charter for Health launched in the year 2000. *

*All Watches tell activists worldwide what issues worry PHM and its
partners, why we denounce them, what consequences loom in the future if
nothing is done about them, what (if anything) is being done about them and
what actions PHM calls for and supports.*

*GHW5 presents to you a decisive global health critique and outlook not
easily found elsewhere.*


*B. HEALTH SYSTEMS: CURRENT ISSUES AND DEBATES.*

*B1. UNIVERSAL HEALTH COVERAGE: ONLY ABOUT FINANCIAL PROTECTION?*

No, not only about financial protection, but much beyond: UHC also is about
quality of care, equality, efficiency and prevention, plus about tax-based
funding and single payer systems.

 PHM is of the opinion that popular movements can and should drive
healthcare reform, and here is why.

While there is some overlap, differences in emphasis between PHC and UHC
approaches are significant. PHC works with communities on the social and
environmental determinants of health, as well as in healthcare development.
This implies a dominant role for public sector providers, simply because
private providers are demonstrably unable to comply with the broader
principles of PHC in their practice. Since 2010, WHO advocates for
abolishing user charges at the point of service. Later, the World Bank
complied. But the warm collaboration between the WB and WHO obscures some
very significant differences in approach. It is basically an unholy
alliance. The differing mandates of the two bodies only align occasionally
as is in the case with their respective approaches to UHC. Add to this the
dependence of WHO and its donors particularly the bullying by the US
demanding WHO and its experts continue acting in a primarily technical
advice role.

In terms of equity, PHC and UHC are not comparable either: Competitive
health insurance markets called by interested UHC proponents provide
different products to different income strata and different benefit
packages according to ability to pay. Certainly, they do not provide for
equitable redistribution of resources through pooling across income levels.
Plans for high income earners end up with looser utilization controls and
more generous benefit packages.

Allocative efficiency is also an import policy goal of UHC, i.e.,
incorporating the distribution of resources across geographic areas, across
workforce segments and institutions with appropriate services and programs.
Resource flows should thus be directed to those regions, workforce and
other categories where there is greater need --and this is not done often
enough.

A marketplace in which providers compete to deliver specified services at
specified prices is simply a weak mechanism for promoting efficient quality
healthcare. Health insurance schemes involve a surrogate purchaser, be it
the health insurance plan or another purchasing agency. Be clear: The
neoliberal solution relies on a competitive market based on the mirage of
providing choices. Such an economistic mindset is nowhere more evident than
in policy discussions involving priority-setting that commonly revolve
purely on technological assessments and options. But not all resource
allocation choices can be reduced to a benefit package design. A much
broader range of conditions need to b e considered in determining
priorities, GHW5 tells us.

The MDGs were as much about relegitimizing economic globalization as they
were about fostering true ‘development’. Yes, more resources were found.
But just having more money for health will not ensure universal coverage!
The ascendancy of UHC was actually partly a response to the failure of
narrow vertical disease-focused global health initiatives. UHC really took
off following the global financial crisis of 2008.

UHC actually can be accused of trying to open new markets for private
investment (including healthcare and health insurance markets). The
proponents of this approach try to force governments to make space for
privatization. This renders inequality acceptable by providing safety nets
for those rendered poor (rather than tackling inequality by adopting
policies that reverse this widening trend).

UHC also provides us a window to look at the dynamics of global governance
in the present era. This is of practical importance for activists who are
struggling to achieve UHC within the right to health framework.

TNCs power is blatantly being used to extort tax concessions and to
pressure countries to liberalize trade in services including medical
tourism.

In short, the UHC discourse being pushed is mechanistic and top-down. The
approach now permeates the technical literature.

It is crucial to internalize the different political realities at play with
which advocates for reform will have to deal. Windows of opportunity open
now and then and have to be seized. The focus must be on the progressive
realization of the right to health and for this, PHM seeks a political
consensus. Using a ‘whole system vision’, localized political pragmatism
must prevail for a bottom-up swell of reform to open new spaces.

When the opportunities arise, appropriate policy ideas must be circulated
to the various constituencies for all to be ready to go for changes
encompassing a broadly shared vision. Activists’ strategies for healthcare
reform need to drive challenges in all these areas and levels.

Xx

*B2. REVITALIZING COMMUNITY CONTROL IN PHC*

In the spirit of Alma Ata, a community consisting of community members can
and should form locally elected boards of management to govern and control
PHC services. Citizens’ involvement in all aspects of healthcare is
considered fundamental by PHM.

PHM’s People’s Charter for Health (2000) rejects tokenistic efforts in this
area. For us, the community has to amass real power over decisions
pertaining to their own health, as well as to improve the responsiveness of
the health services to their local needs. This goal continues to be blocked
and must be unblocked through hard work especially given the current trend
towards privatization. Efforts in this area are more relevant than ever
since existing mainstream health services do nothing more than reproduce
the unfair power relations and thus fail to address the existing
inequalities.

The elected boards are also expected to engage in community development,
advocacy and health promotion with its members setting the scope and nature
of their own participation. For this, a fair amount of community health
education is needed to better respond to local needs by building community
capacity for health.

In essence, community control allows for a more comprehensive PHC vision to
be applied, in line with  the Alma Ata Declaration. Self-determination is
at the core of PHC.

With a focus on the local living conditions, the boards can decide which
issues the health services should address.  These boards are more likely to
undertake work that addresses the social determinants of health and health
equality issues. The view is to democratize health services, as well as
addressing housing, homelessness, poverty, income insecurity, refugee
health services issues. This makes services more culturally respectful. It
is the ability to enact community control that has the potential to
democratize health services. Adding the community perspectives is seen as
complementing and strengthening professional views of health.

Ultimately, we have to make these boards strong advocates for
non-commercialized healthcare by providing a counter-voice to the powerful
corporate voices at play.

PHC continues to be challenged in the era of neoliberalism, austerity and
the privileging of biomedical and commercialized models of health. Activism
here is also a must.

Xxx

*B3. UNDERSTANDING THE MEDICAL-INDUSTRIAL COMPLEX*

This is about the medical-industrial complex the USA’s health system.

The US has an over-regulated market that actually totally escapes market
discipline. Because regulatory capture advances concerns of special
interest groups in America, any true reform would have to dismantle this
unsustainable model. Not all healthcare decisions in it are actually made
by doctors, and if they are, their decisions usually involve flagrant
conflicts of interest. It is easy to identify the big players here by
following the money, i.e., that of insurance companies, Big Pharma and of
for-profit long-term service providers (run by medical elites).

Market-based health systems in America are characterized by their lack of
transparency. No surprise, then, that healthcare outcomes are largely
dependent on patients social and economic conditions. You know that
furthermore insurance companies cherry pick the healthiest persons to sell
them insurance...

The insurance market is ever consolidating via mega-mergers. Much of what
Obamacare did was to subsidize the private insurance system. Rather than
competing, companies found/find it safer to merge with competitors. The end
result is a few very big companies that have no interest in a price war.
This is just the opposite of the supposed benefits of the market.

Is the pharmaceutical industry involved in legal extortion? Well, look at
the facts: The price for patented drugs are estimated to have increased 18%
each year since 2010. The market has become a vehicle for using old and
newly acquired monopoly advantages. Note that the US Medicare Program is
specifically prohibited from negotiating prices with drug companies! This
reflects the lobbying power of Big Pharma. Big Pharma has one of the
largest lobbies in Washington. Unfortunately, under current congressional
rules, this is entirely legal.

It should be clear from this that private entities involvement does not
favor the public’s health.

Any positive role by unions: Only nurses’ unions in the US have been in the
forefront of progressive activism; they should be supported.

In short, the US loses enormous sums of money due to its failed private
programs and to the grossly inflated overhead costs of private insurers.

Eliminating the private insurance system would free up resources now spent
on administrative costs and would allow for healthcare to be provided to
all Americans without increasing taxes or fees (!).

As a worrisome development, US insurance companies have made important
inroads into overseas markets; there are now international hospital chains
and this development of privatization overseas does not make things better;
it just parasitizes the public system. Simply put, the profit motive
corrupts the health care system.

Xxx

*B4.  THE STRUGGLE OF HEALTH WORKERS.*

Experiences here come from South Africa.

After the fall of Apartheid, many key activists moved from civil society
into government. The optimism of this proved to be short-lived. The country
is in the midst of a major health crisis. Average numbers in health
statistics hide great inequality --a major cause of poor health. As there
is a climate of cuts in public spending by the state under austerity,
compounding the problems, donor funding has changed its nature under
neoliberalism directing substantial funding through private
non-governmental organizations.

An important number of community care workers posts have been created.
These agents receive standardized training and work in vulnerable
communities. They have temporary annual contracts, so have no associated
benefits. They also have little support from local health facilities. They
perform a wide range of essential functions in the community management of
important prevalent diseases like HIV and TB. They can also recognize and
start early treatment of life-threatening conditions like pneumonia,
diarrhea, acute malnutrition and malaria. They can further promote
maternal, neonatal and child health. Additionally, they perform simple
curative care and personal prevention, home care of the sick and the
bed-ridden. It is important to point out the scheme has created employment
opportunities for women.

The possibility that South Africa will soon achieve health for all and UHC
appears bleak since the state is unable to make rapid progress tow reducing
inequality, address the social causes of ill-health and establish an
equitable healthcare delivery syst. Private healthcare scouts are using
this weaknesses to lobby for health PPPs.

Add to this, rampant corruption and state capture by rich and powerful
health conglomerates overwhelmingly interested in urban populations.

The above situation calls for massive mobilization for health, one that
turns into a broad social movement in public interest civil society that
will campaign for the right to health for all South Africans. Citizens
action *can* bring about change from below.
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