AFRO-NETS> Food for a Dialectical Thought

[Claudio Schuftan <aviva@netnam.vn>]

Food for a Dialectical Thought
------------------------------


'ELEMENTAL WATSON': THE HEALTH SECTOR REFORM'S FAULTY LOGIC

* Ministries of health around the world claim they have carried out a 
health sector reform; they argue that by doing so, they have decen-
tralized and devolved the governance of the health sector closer to 
the beneficiaries.

* They further claim the stimuli for these reforms come (came) from 
the stakeholders themselves.

* Nothing could be further away from the truth.

* Contradictions between ministries of health and the people they 
purport to serve have not changed a bit with the (often foreign-
driven) health sector reform applied in many countries worldwide.

* An elemental dialectical analysis of the situation would bring this 
clearly to the fore.

* We do not think dialectically anymore; dialectics is supposed to 
have died with the demise of communism in the Soviet Union.

* But dialectics is independent of communism; it is an analytical 
tool that brings out the contradictions among social classes in a 
given society....and the health sector is a sector that badly needs 
to be looked at dialectically if we are ever to solve its growing 
problems.

* Issues of power and control are (and have always been) behind the 
state of affairs we see right now. * Who wins/who loses? What? How? 
Through what mechanisms? and Why? --these are the kind of questions 
we are not asking.

* We need to bring such an analysis of dialectical relations in 
health to a level field --away from the current (im)balance heavily 
tilted towards the haves and with outcomes (and inputs) that are 
mostly controlled by them.

* Why? Because no social progress has ever come from the benevolence 
of the haves.

* Only once we move our analysis back to dialectics, will we realize 
that we are facing an unbalanced relationship: opposing factions that 
are supposed to be involved in a struggle, are not engaged in a real 
struggle right now.

* There is no real de-facto opposition from the users/beneficiaries 
to the policies imposed on them from above (and from foreign lands 
and/or international institutions at that).

* So, what is needed to get back on track for a dialectical analysis 
and actions consequent with it?

* We need to get involved with beneficiaries in consciousness rais-
ing, increasing their political awareness of why they are where they 
are. (Using the "Yes, but why?" didactic technique is a good ap-
proach: we ask people for the causes of what they see/experience and 
keep asking "yes, but why that? to their responses until they get to 
the determining basic, structural and underlying power issues).

* We have to open up the dialogue towards topics like:
* equity,
* health as a human right,
* effective decentralization and devolution of power (democratiza-
  tion) [the latter two already called for by the Alma Ata Declara-
  tion...],
* the role of Globalization on the current state of affairs in
  health,
* the role of international financial institutions (WB/IMF), and
* the role of donors, the UN system and NGOs.

* And more technically, cover topics such as:
* the fee for service system,
* social health insurance,
* local health systems development,
* essential drugs,
* community-managed health programs and co-management of health fa-
  cilities, and
 * joint-decision making.

* These are just some of the tactics to follow to more proactively 
engage in balancing the dialectical struggle in the health sector.

* More elements to use in the struggle should and will come from the 
beneficiaries themselves.

* We should not be prescriptive, but just help open this new avenue.

* We do not even have to reinvent the wheel: see the People's Charter 
for Health at http://www.phamovement.org 

* In short: What is needed now is a start-over, a movement, a grass-
roots revolution in health.

* 'Elemental Watson'!

Claudio Schuftan
Hanoi, Vietnam
mailto:aviva@netnam.vn

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