AFRO-NETS> Food for excessively medicalized thoughts

[Claudio Schuftan <aviva@netnam.vn>]

Food for excessively medicalized thoughts
-----------------------------------------

Human Rights Reader 45

GLOBALIZATION, HEALTH RIGHTS AND HEALTH SECTOR REFORM: IMPLICATION 
FOR FUTURE HEALTH POLICY:

1. In most of the world, Health Sector Reforms (HSR) are sick. They 
are terminally ill --in part due to the Negative Consequences of 
Globalization (G) on the right to health. So we better recognize its 
symptoms. Denial of the symptoms may be a good temporary defence. But 
only until reality imposes itself on us.

2. This reality is that we have been giving technical solutions to 
what are political and human rights problems. Ergo, we cannot medi-
calize HSR any longer!

3. I am hereby sending a call for action. Calls for action are not 
helped by scholarly presentations. When all is said and done, a lot 
more is said than done...

4. We thus have an enormous task in front of us. And to prepare for 
that task, we need to sharpen our debating skills. We need to awaken 
the 'investigative reporter' in us; to constantly go after the human 
rights meaning hidden behind the statistics.

5. Around the world, what the poor people to be served by true HSR 
want is simply more: more justice for their entitlements, more from 
health, more from life, more from history, and more from us!

6. Hereunder are fifty seven 'bullets'; they are in no particular or-
der, but are just primers for you to use to start a meaningful debate 
on this issue.

i - The structural reforms that come with Globalization have nega-
tively affected the most vulnerable segments of society; also, income 
distribution and economic access to health have become much more un-
equal.

ii - Civil society needs to become more organized to challenge the 
power of the states that foster or go along with Globalization and 
progressively neglect their human rights responsibilities in health.

iii - Civil society needs to increasingly be visible as a credible 
negotiator between the people and public powers. It has to become a 
watchdog to contain market and Globalization excesses. They also have 
to raise the awareness of the people re the challenges Globalization 
poses. (Best example: the worldwide People's Health Movement and the 
Politics of Health website). (www.phmovement.org ) 
(www.politicsofhealth.org )

iv - The short-run effects of Globalization on the poor ARE negative 
and significant... So, compensatory policies are being promoted and 
designed to help the poor to deal with, for example, falling health 
standards. But this is reactive/palliative and not proac-
tive/preventive...).

v - What are needed are pro-poor/pro-human rights budgets and growth 
strategies; policies geared towards ensuring that people receive ade-
quate food, education and health care; broad participation in policy 
design and implementation; environmental and social awareness; and 
efforts to combat discrimination: 'As individuals, we beg; collec-
tively, we demand'.

vi - With Globalization, the non-poor benefit disproportionately from 
public spending, their benefits far exceeding the taxes they pay.

vii - Pro-poor structural reforms we so much talk about are yet off-
limits for the macro policy establishment. At the macro level, 'the 
social' continues to be an afterthought. But macroeconomic policies 
should add on to social policies if they are to achieve poverty re-
duction. So far, Globalization treats social welfare as an optional 
extra.

viii - More often than not, 'sound' macroeconomic policies are de-
signed and then social 'band-aids' are applied in order to achieve 
acceptable outcomes.

ix - The social exclusion inherent in neoliberal growth models should 
simply be rejected. We should accept nothing less than social inclu-
sion of the poor.

x - With Globalization, the trend is thus toward a drastic reduction 
of state-based entitlements and their replacement by market-based, 
individualized entitlements... But the invisible hand of the market 
has no capacity to create a decent, human rights-based society for 
all. The law of supply and demand can fix the market price of bread, 
but it does nothing to alleviate hunger, famine and ill-health.

xi - Moreover, with Globalization, priority is granted to efficiency 
over other values such as social justice or environmental sustain-
ability.

xii - We now have to think globally and act both locally and glob-
ally.

xiii - Following the Globalization orthodoxy, recommendations are 
made these days to privatize social protection (but privatizing basic 
social services and social insurance is antithetical to redistribu-
tion and equity... The idea that any pivatization is better than no 
privatization should be rejected.

xiv - In sum, the negative effects of Globalization are reversing 
some of the social gains already made; it is lessening the likelihood 
that developing countries will have the necessary policy autonomy and 
fiscal capacity to carry out and finance comprehensive health poli-
cies.

xv - Although NGOs have enjoyed a high profile in recent years they 
have mostly remained in the reactive mode. There are signals that 
their heyday is over. Many stand accused of complacency and self-
interest on the one hand, and of being ineffectual and irrelevant on 
the other.

xvi - Globalization has brought about a shift in power: the nation 
state has weakened and there is a reduction in social accountability. 
Moreover, 'in the dealings of Globalization', its intricate connec-
tions are so patently disguised as to become almost invisible. Or 
worse, the deceptions are so brilliantly woven into its processes 
that falling for those deceptions is deemed as both fashionable and 
progressive.

xvii - Due to these negative consequences of Globalization, communi-
ties in many Third World countries are no longer able to cope --their 
previously successful coping strategies diminishing daily.

xviii - Governments in the Third World are simply assumed to be inca-
pable of assuming a minimum level of welfare for their citizen. It is 
implied that it is necessary to look for alternatives in the private 
sector or to directly privatize services (...and NGOs are occasion-
ally a convenient form of privatization). Only that, often, such pri-
vatization strategies lower the quality of services for the poor and 
end up widening the gap between the rich and poor.

xix - Under Globalization, the annual losses to developing countries 
run at an estimated $500 billion --an amount much higher than what 
they receive in foreign aid.

xx - Whatever the response, promoting the economic benefits of Glob-
alization requires mechanisms to prevent its excesses --including the 
human rights violations it aggravates--, because there is a clear 
trade-off between market efficiency and the social welfare of workers 
and peasants.

xxi - In the international scene of (mercenary) technical development 
assistance, for example, issues of substance are turned into techni-
cal matters by paid consultants while underlying more structural is-
sues get obfuscated. Or --what amounts to the same-- aid agencies too 
often remain unwilling to respond politically to political situa-
tions.

xxii - Remedies proposed to specifically increase equity and access 
to basic services thus include targeting of subsidies (i.e. selective 
subsidies of goods and services disproportionately consumed by the 
poor), prepayment plans (e.g. community-based health insurance), ex-
emptions and the selective dropping of some fees (e.g. health and 
educational), prevention and on improvements of the quality of care 
(in health), as well as on a fairer urban/rural distribution of re-
sources.

xxiii - Expenditures on health have to increase, they say, but to be 
equitable, they have to be concentrated on preventive activities in 
rural areas and should be targeted to the lower income quintile.

xxiv - Globalization may be inevitable, but what it looks like is not 
--there are forces that can shape it, and human rights must be one of 
those forces.

xxv - Actually, with Globalization, "Might is Right" has come back 
with a vengeance. And in a defeatist stance, we have so far accepted 
this fact and have bowed to the forces we think we cannot effectively 
oppose. Soft approaches will not do. Bolder steps will have to fol-
low.

xxvi - Furthermore, we have to fight the indifference of our youth to 
the present global situation: our young and upcoming colleagues. We 
have thus to enroll the youth before they resign themselves... Our 
youth seems more interested in the information superhighway.

xxvii - In sum, an effective challenge against Globalization and its 
negative effects on health is possible, but demands the same kind of 
intellectual commitment and vigor that characterized anti-colonial or 
independence struggles.

xxviii - Western intellectuals have simply abandoned their commitment 
to challenge the exploitation and oppression of the poor as they con-
tinue being brought about by Globalization. Concerted campaigns and 
struggles against poverty, tyranny any exploitation will form the 
only sustainable basis of an intellectual renaissance of our youth 
and of ourselves.

xxix - Taking a minimalist stand towards Globalization will do no 
harm, but neither will it do much good. Inertia in history (has) and 
will always work(ed) against the more visionary and radical changes 
deemed necessary when the same fall outside the ruling paradigm.

xxx - Development cooperation must thus become more political and 
more human rights oriented, because only structural reforms will de-
liver sustainable and fair development.

xxxi - The solutions to the consequences of Globalization on the 
health and nutrition sector, for example, cannot be medicalized any 
longer. Technical assistance focused on health/nutrition matters only 
is not enough to uproot the structural inequities underlying perva-
sive and unrelenting ill-health and malnutrition in the world.

xxxii - But the inertia is so great and our collective virtual view 
of reality so distorted and entrenched, in part due to Globalization, 
that the likelihood of us changing that reality remains dim.

xxxiii - In short, we need to give a larger intellectual and politi-
cal scope to our discussions on Globalization. In doing so, we have 
to manage to develop a political program of more universal appeal. We 
need to come up with a focused common agenda.

xxxiv - When economics has ceased to strengthen social bonds and its 
prescriptions are actually further pauperizing millions, it is time 
to start thinking in political terms again. This is one of my cher-
ished iron laws.

xxxv - The facts discussed here are more than enough to allow us to 
go negotiate (or struggle) for new more radical equitable/pro-
poor/pro-women/pro-human rights based strategies on the highest of 
moral grounds.

xxxvi - Globalization does not have a human face; power differentials 
are at its crux. It is a process we cannot wish away.

xxxvii - When government expenditures in health in developing coun-
tries are shrinking, the World Bank has them pushing for a greater 
role of market forces in the production and distribution of health.

xxxviii - Providing health care as a human right and on the basis of 
need is being replaced by a system based on cost recovery where ex-
emptions for the poor have not worked.

xxxix - Safety nets are nothing but a way to manage poverty attenuat-
ing social unrest.

xxxx - The politics of health will override all other efforts to 
bring us Health for All. (Equity is the forgotten key thrust of Alma 
Ata!... this year in its 25th anniversary!). A renewed commitment and 
resolve to foster empowering community-based activities will have to 
guide our actions.

xxxxi - Countering the forces of Globalization is a step towards eq-
uity; it is futile to look for an accommodation to fit greater health 
into an inherently inequitable system. This, because some of the HSRs 
measures are actually Structural Adjustment measures in disguise.

xxxxii - At the same time, reforms being proposed to strengthen pub-
lic health policies and public financing of health via taxes are be-
ing dismissed as being supposedly non-viable. But the so often pro-
claimed non-service mindedness of the public sector is not a given; 
we need to fix a system that, granted, has many flaws. But it also 
has many strong points!

xxxxiii - Evidence that market-oriented health care systems are more 
efficient are not really well founded (look at the USA.); they are 
just more profitable to some and too often provide unnecessary care.

xxxxiv - Conversely, evidence that public health care systems are 
more equity-oriented and can be made more efficient, does exist.

xxxxv - The cost recovery system is a regressive tax in which the 
poor pay as much as the non-poor; becoming sick thus penalizes the 
poor more, and high fees for health care are a major cause of pau-
perization.

xxxxvi - Direct and indirect progressive taxes (and non-private in-
surance schemes) must thus constitute the financial basis in an eq-
uity-oriented health care system.

xxxxvii - So, if our objective is to provide care according to need, 
our only choice is to improve public health care systems that cater 
to those with less ability to pay (the majority).

xxxxviii - Another perennial problem of HSRs is that decision-making 
has allowed limited involvement of the beneficiaries themselves.

xxxxix - Bottom line, HSRs have been used as crutches to pretend one 
is changing the system, but basically staying the course or even go-
ing backwards. And this is not by accident.

L - HSRs alone cannot simply address the human rights and structural 
constraints to equitable health, not even with good targeting.

Li - Tinkering with the current HSR models will simply not do. This 
is the sad reality. Precious time is likely to be lost only to see 
the problems of inequity worsen.and what is inequitable today will be 
inhuman tomorrow.

Lii - So what would be more effective and sustainable? a) First, it 
is not for us in this distinguished virtual gathering to come up with 
the responses. b) For once, it would be best to ask the beneficiaries 
directly to respond to this question rather than coming up with some 
technical responses. c) A bottom-centered approach calls for a radi-
cal change in our priorities and our modus operandus: The locus of 
control has to shift to the beneficiaries. d) The bottom line is that 
--together with the beneficiaries-- we need to articulate a more sus-
tainable Equity-Oriented Health Sector Reform (EOHSR).

Liii - There is no such a thing as 'lack of political will'. What 
there is, is a laissez-faire, the manifestation of a choice made, 
i.e. a choice not to exercise a will!

Liv - Contradictions between ministries of health and the people they 
say they serve have not changed a bit with the (often foreign-driven) 
HSR as applied in many countries worldwide.

Lv - Who wins/who loses? What is won or lost? How, through what 
mechanisms? and Why? --these are the kind of questions we are not 
asking.

Lvi - We need to get involved with beneficiaries in consciousness 
raising, increasing their rights awareness and their political aware-
ness of why they are where they are.

Lvii - In short, what is needed now is a start-over, a global move-
ment, a grassroots revolution around the right to health.

Claudio Schuftan
Ho Chi Minh City, Vietnam
mailto:aviva@netnam.vn
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