OUR STRUGGLE IS NOT FOR GLOBAL HEALTH JUSTICE; IT IS FOR GLOBAL HEALTH AND JUSTICE, AS WELL AS FOR GLOBAL HEALTH WITH JUSTICE. (Lawrence Gostin)

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Right to health: Food for a de-commodification thought

 

Human Rights Reader 390

 

  1. The reason why global health policy-makers are not implementing the knowledge generated by global health scholars with the right empirical, every-day experience, is not because they use different normative standards; it is because, when selecting priorities, too many policy-makers are politically constrained by the interests and the power structures in their environment. The conflict is not a difference in normative opinion, but rather a political issue. (C. Askheim)

 

  1. Alex Scott-Samuel speaks of ‘fantasy paradigms leading to health inequalities’ or, as he says, of utopian health thinking’. He argues that in this world fantasy its proponents describe how global policy officials tend to write and speak within a parallel world in which the political economy of the global economic crisis and the brutality of imperial geopolitics do not exist and add that global health policies must simply comprise cost-effective interventions, political promises and philanthropic largesse.

 

Choices on offer in health care attract consumerist sympathy

 

  1. Fact: The appropriation of health care by business is being legitimized by policy makers –and, with that, goes the loss of the ideas of citizenship and solidarity implicit and explicit in social rights. So strong has the pressure to extend capitalist appropriation in the profitable domain of health care been that not even ideological consistency has been respected: Actually, neoliberal principles such as efficiency have themselves been ignored. In poor countries, excessive emphasis on cost-effectiveness has brought health care systems not only not to focus on the most vulnerable, but also to be run in an economically unsustainable way. Since the middle and upper classes are more likely to have their voices heard, their more exclusive and expensive health care needs are prioritized to the detriment of the vast majority of the people rendered poor. What social rights primarily demand is the de-commodification of key areas such as the provision of health care, education and other essential social services. (Eduardo Arenas)

 

  1. As regards the effects of privatization on research, note that influential randomized trials are largely done by and for the benefit of industry. Moreover, fashionable meta-analyses supposedly leading to guidelines have become a factory also often serving vested interests. National and international research funds are funneled almost exclusively to research with little relevance to global health outcomes. Bottom line here, under market pressure, clinical medicine has been transformed to finance-based medicine. (John Ioannidis)

 

  1. We thus need a whole new wave and breed of public interest civil society health activism to address what has been called the “GLP” virus (standing for Globalization, Liberalization and Privatization) that is causing a monumental global health divide that has become shocking if not criminal. (Anwar Fazal)

 

Our human rights struggle in health focuses on addressing the eminently social function of health and nutrition (Malik Ozden, CETIM)

 

  1. Let me start with a caveat: It is not an innocent stands when colleagues and whole health systems attempt to reduce the right to health to the-right-to-receive-medical-care.* For the right to health to become a reality, policies of all sectors must fall into place. Further (and much) more, the fulfillment of the right to health requires the social mobilization of claim holders to grow steadfastly –to demand the needed changes. (Julio Monsalvo)

*: This is typical for countries that, despite high levels of economic growth and of consumption, have not implemented the needed institutional reforms that guarantee homogeneous progress by deliberately giving priority to measures in the realm of social and human development. Yes, inequality is unfair and cruel, as well as unacceptable in a society striving to be called ‘developed’. (Foro Salud Peru)

 

  1. Why the caveat? Because the right to health simply has to guarantee:
  • universal and comprehensive health care that includes claim holders’ active participation;
  • an increase in the public expenditures on health with priority given to address the needs of the neediest;
  • universal access to generic medicines and essential medical equipment including sovereign pharmaceutical policies;
  • a rejection of the signing and ratification of undemocratic and unfair trade agreements;
  • quality health care and dignified treatment;
  • a closing of the gap in essential health personnel and their needs;
  • addressing the social determinants of health and pursuing active health promotion activities and, last but not least,
  • addressing the special needs of women, gender issues and all issues of sexual and reproductive health. (Foro Salud, Peru)

I ask: How can all this possibly be achieved using a top-down approach?

 

  1. For our colleagues in El Salvador, the right to health tasks at hand further include:
  • The immediate abolition of all payments in the public health system allowing an increase in the access to health according to need all the way to the tertiary level.
    • Passing legislation that regulates the prices of medicines nationwide.
    • Giving a decisive push to citizens’ participation in the planning and monitoring of health policies from the primary to the tertiary level.**
    • Setting up immediate and ongoing evaluation mechanisms of the delivery of patient-friendly, non-discriminatory health services.**
    • Giving No.1 priority to comprehensive primary health care with ad-hoc health care teams assigned to specific geographic areas.
    • Organizing and coordinating the sector’s claim holders to coalesce into public interest civil society pressure groups.

**: But the health indicators currently in use are ambivalent; some advance slowly (…and more for some in society) while other stay put or deteriorate. The time for less-than-useful statistics to yield to right-to-health-sensitive data has come; reality and truth must impose themselves on the data being/to be collected so that social and health policies start addressing real human and citizens’ needs. (Foro Salud Peru)

 

  1. Given the above, organized claim holders, therefore, must:
  • Urgently organize and mobilize to repeal irresponsible public policies that highlight economic growth, but hide stagnating poverty indexes. [Perpetuating the use of national averages in health statistics is an example of how this hiding operates].
  • Use all their energies to negotiate/demand the needed political changes/compromises based on pragmatic and legally-binding measures that will fulfill the right to health for all. [The dialogues with government and with public opinion leaders (duty bearers), as well as the claimants’ presence in the public debate through the media must be matched by their organizations’ capacity to monitor health policies (their application) and health statistics (their use) in all health services].
  • Work within a political framework that actively pursues the right to health and that deepens all people’s participation making sure they achieve not only voice, but influence as the only way to guarantee needed changes are eventually made. [An effective popular participation is the key element that gives legitimacy to the claim holders’ human rights (HR) protection struggle and gives legitimacy to their fight against the stigma, the discrimination and the exclusion that affects so many in their quest for quality health care].
  • Demand that health interventions apply HR principles and standards respecting all international HR covenants and conventions.
  • Consolidate an active and wide social and political movement that will address the social determinants of health face-on. [The commoditization and the medicalization of health are just two examples of important determinants of people’s health that need to be tackled].
  • Involve the above movement much more with the struggle for a cleaner and cooler environment.
  • Lobby for the curricula of health professionals to be amended so as to revert the current model being taught centered around treating diseases and increasing the productivity of the health work force. [Breaking with the biomedical model is urgent since it leads individuals and society to situations detrimental to health].
  • Become part of the struggle for fairer remuneration of the health workforce, and
  • Denounce, amend and/or revert all the current measures that affect HR and people’s liberties. [An example is all current and in-negotiation free trade agreements]. (Foro Salud, Peru)

 

In the Universal Health Coverage era: Is health equality a sibling of the right to health?

 

  1. If and where universal health care (UHC) is implemented in line with the recommendations of WHO, it is said it can come close to being anchored in the right to health. But is it? Let us see:
  • First, UHC anchored in the right to health requires that cost–effectiveness criteria are used with much more care to avoid justifying UHC when it is not complying with the minimum principles and standards demanded by the right to health.
  • Second, identifying and overcoming the multiple barriers stemming from socioeconomic exclusion and/or discrimination is certainly vital to advancing UHC –but it is not sufficient in itself. Efforts are required to identify the specific groups that are vulnerable or marginalized in a given country and region(s) to make sure they are included in all UHC plans so as to ensure that health coverage is truly universal.
  • Third, comparing UHC and right to health norms highlights the difference between a UHC anchored in the right to health and UHC not explicitly anchored in the right to health. (Ooms)

 

The right to health demands a set of core obligations that apply to all countries, regardless of their wealth

 

  1. The right to health guarantees a minimum level of health care –anywhere. In that sense, UHC cannot have any kind of ‘floor’. If the economic context of a given country leads to a level of health care that does not even address standard health threats of the most vulnerable, how can UHC, as currently proposed, tolerate that? Beware: Such a UHC does not guarantee a commensurate level of core health care entitlements to vulnerable groups as the right to health does. Furthermore, UHC norms pay little attention to vulnerable and marginalized groups in terms of their active participation in decision-making. (Ooms)

 

  1. Bottom line, if UHC is not anchored in the right to health it risks not being universal with respect to providing coverage to all people. It is the focusing on coverage percentages not disaggregating data by vulnerable groups what masks exclusion. The complex interplay between social marginalization or exclusion and economic exclusion can render vulnerable and marginalized individuals (e.g. the child of an unmarried, undocumented migrant) and groups invisible to the authorities. Addressing this added dimension of exclusion is thus a priority if UHC is to be anchored in the right to health. Procedurally, UHC anchored in the right to health requires that authorities engage with those who are excluded and devise policies with them to amend the health system accordingly –actually the whole social system more broadly. Only this will make UHC truly universal. (Gorik Ooms for WHO)

 

Universal Health Coverage, taxes and wages

 

  1. Tax revenue is a major statistical determinant of progress towards UHC. Each U$10 per-capita increase in tax revenue is associated with up to an additional U$1 of public health spending per capita. Whereas each $10 increase in GDP per capita is statistically associated with increases in the order of U$0.10. Crucially, tax revenues sit on the pathway between economic growth and health spending. In short, tax reform is an efficient way of translating economic growth into greater health spending. Over time, taxation within a country is associated with changes in infant mortality. The results have been crystal clear. Where taxes on goods and services increase (thereby increasing the cost of food and health care), infant mortality also increases.  However, where taxes on income, profits, and capital gains increase (progressive taxation), we do not find this same relationship. Some countries can further increase revenues through reducing corporate tax evasion. Bottom line here, tax is a cornerstone on which we can achieve UHC. (A. Reeves)

 

  1. The above notwithstanding, defending wage subsidies to secure a ‘basic income’ is not the solution for UHC; we ought to think twice before defending this. Receiving a ‘better’ basic income to only then have to pay for privatized health services will certainly not tackle inequalities. (Francine Mestrum)

 

Claudio Schuftan, Ho Chi Minh City

cschuftan@phmovement.org

 

Postscript/Marginalia

 

Twelve arguments pointing towards why we need to embark on empowering community capacity building activities in health (From HR Reader 15)

 

  1. The notions of duty and justice (…and not compassion!) give the right to health its cutting edge.
  2. Power is a key relation between health and HR issues. A right confers power, i.e. the power to make key changes as far reaching as the prevailing health system allows claim holders to demand for. (It is our duty to help making the latter possible).

III. People have full power only when they are able to alter existing power relations. (It is our duty to help making this possible too).

  1. X has to have power over Y to affect results. Power thus needs to be used to change an existing unfair health system and to turn it to the people’s advantage. (It is our duty to help this use is made).
  2. Only exercising power can people freely select among the realistic available possible solutions (people’s empowerment is thus needed).
  3. Active claims are rather useless if there is no power to have duty bearers enforce their public health duties.

VII. A party other than the duty bearers has to have power over the duties in order to make sure most public health duties are enforced.

VIII. Ergo, to enforce a duty, the claim holder needs power over the duty bearer.

  1. It is not good if the claim holders have no power or control over the enforcement of their health claims.
  2. Actually, people can only have a true health claim when they also have the power to claim for it; the power is a necessary ingredient in their claim; ergo, having a claim necessarily involves having (or acquiring) power.
  3. Claim holders cannot only be passive beneficiaries of the duties of others.

XII. People’s health rights are recognized as long as the claim holders have power over the duties not being enforced.

 

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