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<p class="MsoNormal"><span style="font-size:10.0pt">Human Rights Reader 291</span></p>
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<p class="MsoNormal" style="text-autospace:none"><b style><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular">WHAT CAN WE DO TO INTENTIONALLY
SHAPE OUR COLLECTIVE DESTINY? </span></b><span style="font-family:PlantinMTPro-Regular">(part 1 of 2)</span></p>
<p class="MsoNormal" style="text-autospace:none"><b style><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular"> </span></b></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:10.0pt;font-family:PlantinMTPro-Regular">[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]. </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-family:PlantinMTPro-Regular"> </span></p>
<p class="MsoNormal" style="text-autospace:none"><cite><span style="font-size:14.0pt;font-style:normal">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</span></cite><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular"> </span><cite><span style="font-size:14.0pt;font-style:normal">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. </span></cite></p>
<p class="MsoNormal" style="text-autospace:none"><cite><span style="font-size:14.0pt;color:blue;font-style:normal"> </span></cite></p>
<p class="MsoNormal"><cite><span style="font-size:14.0pt;font-style:normal">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). </span></cite></p>
<p class="MsoNormal"><cite><span style="font-size:14.0pt;font-style:normal"> </span></cite></p>
<p class="MsoNormal"><cite><span style="font-size:14.0pt;font-style:normal">3. </span></cite><span style="font-size:14.0pt">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 <u>system oriented to the
promotion of the interests of the rich</u>.*</span></p>
<p class="MsoNormal"><span style>*: 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?<span style="color:blue"></span></span></p>
<p class="MsoNormal" style="text-autospace:none"><span style> </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt">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, p</span><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular">olicy 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.</span></p>
<p class="MsoNormal"><span style="font-size:14.0pt;color:blue"> </span></p>
<p class="MsoNormal" style="text-autospace:none"><b><span style="font-size:14.0pt">A crisis of capitalism?</span></b></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular">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 G</span><cite><span style="font-size:14.0pt;font-style:normal">lobalization 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 <u>and</u> --let us not
overlook-- <u>sub</u>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. <span style="color:blue"></span></span></cite></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular"> </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular">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.</span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular"> </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular">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.</span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular"> </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular">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.</span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular"> </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular">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. </span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:PlantinMTPro-Regular;color:red"> </span></p>
<p class="MsoNormal" style="text-autospace:none"><b style><span style="font-size:14.0pt">Repercussions on Primary Health Care</span></b></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt">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.</span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt"> </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt">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<u>
services both in urban and in rural areas</u>.</span></p>
<p class="MsoNormal" style="text-autospace:none"><span style>**: For
long now, t</span><span style="font-family:PlantinMTPro-Regular">he 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. </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style> </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt">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.</span></p>
<p class="MsoNormal"><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular;color:red"> </span></p>
<p class="MsoNormal" style="text-autospace:none"><b style><span style="font-size:14.0pt">Repercussions on health care financing</span></b></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt">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</span><span style="font-size:14.0pt"> </span><span style="font-size:14.0pt">ideology that is getting in the way of finding progressive solutions. </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt"> </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt">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<u> financial
sustainability</u>.</span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-family:PlantinMTPro-Regular">****: 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. </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style>*****: Note
that traditional public health and actuarial research uses a <i>risk-factor </i>approach;
such an approach fails to reveal multi-causal mechanisms and to reveal the root
causes of health inequities.</span></p>
<p class="MsoNormal" style="text-autospace:none"><span style> </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt">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 <u>and</u> 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.</span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt"> </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt">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. </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt"><span style> </span></span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt">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).</span></p>
<p class="MsoNormal" style="text-autospace:none"><span style> </span></p>
<p class="MsoNormal" style="text-autospace:none"><b style><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular">Repercussions on maternal
mortality</span></b></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular">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) </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular"> </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular">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.</span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular"> </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular">20. Furthermore, the life-cycle approach preferred by several new-age
maternal health rights proponents continues to identify reproduction as <i style>the</i> 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. </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular"> </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:14.0pt;font-family:PlantinMTPro-Regular">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.</span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:10.0pt;font-family:PlantinMTPro-Regular;color:red"> </span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:10.0pt;font-family:PlantinMTPro-Regular">Claudio Schuftan</span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:PlantinMTPro-Regular"><a href="mailto:cschuftan@phmovement.org">cschuftan@phmovement.org<span style> </span></a><span style> </span></span><u><span style="font-size:10.0pt;color:blue"></span></u></p>
<p class="MsoNormal"><u><span style="font-size:10.0pt">____________________</span></u></p>
<p class="MsoNormal"><span style="font-size:10.0pt">Summarized and adapted from </span><span style="font-size:10.0pt">Global Health Watch 3, An Alternative World Health Report. People’s Health
Movement, Zed Books, London and New York, October
2011.<span style> </span></span><cite><span style="font-style:normal"><a href="http://www.ghwatch.org/ghw3">www.ghwatch.org/ghw3</a></span><b><span style> </span></b></cite><cite><b><span style="font-style:normal"></span></b></cite></p>