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[afro-nets] In preparation of People's Health Assembly II - part 23

  • From: Claudio Schuftan <claudio@hcmc.netnam.vn>
  • Date: Mon, 20 Dec 2004 13:53:24 +0700

In preparation of People's Health Assembly II - part 23

Neoliberal ideology in the World Health Organization: Effects on
global public health policy and practice

(Part 2 of 4)

Four flawed assumptions

a) 'Economic growth is the aim'

Economic growth is not necessary related with improvements in
health nor with improvements in human welfare generally. How-
ever, the international health community continues to present
growth --through Globalization and free market policies-- as the
aim with the assumption that benefits, including improved
health, will trickle down to the poor (even though such a theory
has long been discredited).

During the period of Globalization and free market policies pre-
dominance, not only have poverty and inequality between and
within countries accelerated, but social progress, including in
public health, has declined. Neoliberalism fails to distinguish
between two periods: 1960-1980 and 1980 -2000. In the latter pe-
riod, per capita GNP growth has been considerably worse in all
countries and the poorest countries experienced negative growth
and considerably slower progress in life expectancy and infant
and child mortality. Many authors have stressed that "these re-
sults cannot be explained by the AIDS pandemic". This correction
is important because the neoliberal establishment has conven-
iently identified AIDS as the cause rather than the result of
the poverty, hunger, devastation and chaos experienced by sub-
Saharan and other countries.

Furthermore, economic growth is not synonymous with a sustain-
able and equitable use of resources which is a prerequisite for
peace, social justice and public health. If the international
health community is serious about Health for All -NOW, it cannot
continue to ignore alternative economics. It should not be for-
gotten that the Alma Ata declaration in effect endorsed "distri-
bution economics" through its support for a New International
Economic Order.

The link between fair and sustainable use of the earth's re-
sources and countries' capacities to meet people's basic needs
for health is undisputable in ethical and common sense terms --
and as the accumulated evidence shows. Basic health needs, in-
cluding a safe environment, can only be met for all the world's
people if scarce resources are distributed fairly and produced
and consumed carefully.

In the social justice and human rights approach to health fea-
turing a re-appropriation of WHO by the people, the economic
growth paradigm must be replaced by a fair distribution and sus-
tainable use of resources paradigm as the underlying economic
arrangement for needed changes in health and development.

b) 'Health is what you get from health services'

For neoliberals, health is achieved and health problems are
solved by delivering technical interventions through health ser-
vices. In a great number of UN and WHO documents, there appears
to be no recognition that the major interventions required for
improvements in public health status lie outside the health sec-
tor. WHO's own figures, year after year, show that determinants
of disease in poor countries today are roughly the same as they
were in today's rich countries 100 years ago.

50-70% of lower respiratory infections, diarrhoeal disease, ma-
laria and measles (the big killers) in childhood are due to un-
der-nutrition. 88% of diarrhoeal disease is due to unsafe water,
sanitation and hygiene, and 99% of deaths due to these risk fac-
tors are in developing countries.

It would appear that classic public health lessons are not re-
garded as applicable to poor countries today. The international
health community has been recommending technologies to fight
disease in developing countries for at least two decades -
drugs, bed nets, condoms and the like --in short, cosmetic, un-
sustainable, stop gap measures.

The neoliberal establishment never acknowledges that poor coun-
tries today may wish to rid themselves of the scourge of disease
reliably and once and for all (just as the rich countries did)
rather than for a couple of months --while supplies of donated
drugs or vaccines last.

It should not be assumed that this is some kind of unfortunate
mistake. Like all the policies proposed for poor countries by
the international financial institutions, such prescriptions re-
inforce existing power balances and mostly serve those who de-
sign them.

Another peculiarity of the neoliberal approach to health is the
obsession with research to develop new technology and to "im-
prove the evidence base". If the aim is to reduce the greatest
burden of disease, which everyone agrees is attributable to un-
clean water and malnutrition, no new evidence is required.

The interest in developing new technologies is twofold: It
represents an additional diversionary tactic --this time from
the simpler solutions that exist-- and it is of considerable in-
terest to transnational corporations especially those in the
pharmaceutical products and medical equipment business.

In conclusion, it is argued that the underlying assumption
'Health is what you get from a health service' should be re-
placed with the alternative approach that states that Health is
what you get from meeting basic people's needs, PHC included.

c) 'International aid is the only way to finance health'

A frequent omission from UN and WHO texts on health, poverty and
development is the concept of distribution of wealth in the
world. A narrow and static vision of economic arrangements in
the world is proposed in which there are rich, donor nations and
there are poor, recipient countries with no connections made be-
tween the two. The social justice approach to health rejects
poverty as a fact of life and focuses attention on impoverish-
ment as a process which is inherent to capitalist accumulation
and the inevitable concentration of power and wealth.

In neoliberal thinking, the only source of financing for health
action in developing countries is international aid or charity.
Given the pitiful levels and questionable value of international
aid, this perspective is deeply flawed.
International aid is not designed to change the structure and
dynamics of relations between North and South. On the contrary,
it is fully integrated into the current international financial
architecture in terms of its goals and values. Aid brings more
money back to the donor country than is actually 'donated' --and
it inevitably results in undue influence if not outright inter-
ference in public policy (including national health policy) in
the recipient country.

There is a striking disproportion between the amounts raised
through international aid and the amounts which would be re-
leased through simple macroeconomic measures to halt and then
reverse the flow of resources from South to North. International
aid totals around US$ 50 billion annually. In 2001, indebted
countries paid out US$ 382 billion to service their debts. UNC-
TAD estimates that developing countries lose US$ 700 billion an-
nually from unfair trade. And US$ 160 billion could be raised
annually if earned income from offshore accounts were taxed.

The social justice approach to health rejects the assumption
that international aid is the way to finance health and proposes
as an alternative approach: A fair and rational international
economic order so that sovereign states may meet the needs of
their people sustainably and without external interference. Such
an approach is respectful of human rights, national sovereignty
and democracy and offers a sustainable and equitable perspective
on health and development.

d) 'Representative democracy respects human rights'

Many UN and WHO documents purport to convey faith in democracy,
fairness and respect for human rights --as practiced today in
rich countries and preached to poor countries. Ironically, many
of these texts and in particular those addressing health, pov-
erty and development, prescribe to countries a very particular
strategy in matters which are properly of national sovereignty
(e.g., budget levels for health or choice of overall economic

There is a crisis in democracy today (nationally and interna-
tionally) which goes far beyond the minor imperfections which
have always been acknowledged and are occasionally addressed.
The more imperfect our democracies become, the louder our lead-
ers proclaim their attachment to its principles. Behind the
scenes, many of them violate its most fundamental principles
with increasing impunity. At the same time, all five of the in-
divisible human rights (political, civil, social, economic and
cultural) are grossly violated by the same forces which are un-
dermining democracy.

At the international level, gross interference by the powerful
nations, in particular the USA, in the democratic processes of
developing countries is well documented. Suffice it to say that
almost every legitimate people's movement for democracy in de-
veloping countries has been crushed --with violence that ranges
from sudden, extreme and overt to slow, long, drawn-out and cov-

It is argued that the neoliberal approach to health is more or
less antithetical to a social justice and human rights based ap-
proach to health. WHO faces the considerable challenge of recon-
ciling the irreconcilable - namely its own Constitution and the
UN Charter with neoliberal ideology and policy as imposed by the
IFIs, in particular the World Bank --which is today the major
player in global health policy making.

The policies the WB promotes (and imposes through other IFIs)
are: a retreat of the state, privatization of national assets,
deregulation (which in effect removes key areas of the economy
from democratic control), and export-oriented production at the
expense of national self sufficiency. They would all appear to
be incompatible with sustainable development and indeed with de-
mocracy and human rights.

The assumption that the powerful nations responsible for today's
world order are models of democracy and respect for human rights
must be recognised for what it is: pure propaganda.