Do not sweep this under the carpet: Health entitlements are claimable human rights.
Human rights: Food for a claimable thought ‘The right to health’
Human Rights Reader 555
DO NOT SWEEP THIS UNDER THE CARPET: HEALTH ENTITLEMENTS ARE CLAIMABLE HUMAN RIGHTS.
-From anti-retrovirals to vaccines, to emergency obstetric care, to family planning, to access to abortion…: all are inalienable human rights (HR).
[TLDR (too long didn’t read): This Reader is about the negative consequences of globalization on the right to health and the futility of some of the health sector reforms being implemented --including the privatization of services. For a quick overview, just read the bolded text].
Solutions to the negative health consequences of globalization cannot be medicalized
1. What this means is that medicine cannot bring remedy to the structural inequalities brought about today by globalization (…and yesterday, by capitalism under any of its previous names). As such, excess preventable maternal and child mortality* actually have their roots in powerlessness. As such also, parents will continue to have many children in countries rendered poor, no matter how vigorously the discredited ‘birth control’ measures are pushed; this, precisely because it is not in those parents’ best interest to do otherwise.
*: The US is now the only country rendered rich that does not insure for health care for minimum income families with young children and the only one that has not yet established a program for child care services for working mothers.
Public health services have too often become indistinguishable from services offered by corporate providers; worse still: they imitate them (Jacques Toubon)
-Privatization purports to advance the cause of health, but it is no good to give more to those who already have more.
2. Take the medical specialization drive so common in the private health sector: For Mao Tse Tung, overspecialization (as we see it in the last 30+ years) has led to deepening class differences; technical proficiency, for him, counted less than political awareness and political commitment and savvy.
3. Following Mao’s perspective, the COVID-19 pandemic should briskly awaken us from the depths of our neoliberal fantasies. With hundreds of thousands of tragically and unnecessarily lost lives, with a for-profit health system that does not ensure basic public health, Keynes would bid us to launch a new era of economic and social justice, using the powers of government for our health, our well-being, and our economic needs. (Jeffrey Sachs)
After the world’s McDonaldization what will it be? It will soon be McHealth, McSchools and McAgriculture (Susan George)
4. The basis of the growing anti-state bias** is the over-and-over repeating that governments are simply incapable of assuming a minimum level of welfare for their citizens. Nonsense! In the name of that false and intentional logic, it is thus considered necessary to look for alternatives in the private sector or to outrightly privatize public services. What is not said is that, often, such strategies lower the quality of services and --most worrisome-- end up widening the gap between those rendered rich and those being rendered poor. The HR to health just being one example.
**: Speaking of biases, the notion that welfare recipients are well-off is also nonsense: They are mostly spending less on food than the cost of a nutritionally adequate diet and more than 60% of them are children (mostly young children) and mothers who try to care for them plus people with severe health problems and/or that cannot find a job. Yet the popular misconception that all welfare recipients are lazy is widespread.
Target not those rendered poor, but the process of them being rendered poor!
-Many currently proposed approaches to resolve health problems, including the ones from the World Bank, other external funders and international NGOs, focus on targeting.
-Targeting interventions misrepresent complex realities and distort more realistic policies that address underlying structural determinants. Furthermore, international target setting involves big costs in monitoring and it destroys the political momentum of empowering claim holders. (Simon Maxwell)
5. Let us be clear: It is a fallacy to propose targeting as an alternative to comprehensive primary health care (PHC) as originally conceived in Alma Ata. Individual targeting is equivalent to the discredited ‘selective PHC approach’: “Go for the worse cases, fix them and improve the statistics”. But where are the sustainable changes to avoid the recurrence of the same problems and mistakes to be seen?
6. Targeting keeps a semblance of equity. Targeting can and does stigmatize those rendered poor creating 2nd class citizens that can be manipulated. Individual targeting is not a substitute for a more redistributive public policy. Geographic targeting has more potential --if the area(s) chosen is(are) poor. Starting with targeting interventions as the central thrust to achieve equality is the wrong approach; it pursues what is rather a ‘mirage of equality’. It tacitly blames those rendered most vulnerable for being where they are and tends them a crumb of bread as a rescuing hand. Ergo, target not those rendered poor, but the process.
Various versions of health sector reform are then proposed
7. Health Sector Reform (HSR) is a process that seeks changes in health sector policies both financially and in the organization of services, as well as in the (diminished?) role of government to reach national health objectives. Currently (and in the past) HSR is (was) mostly imposed from above and from outside the sector. So, who is deciding? The Ministry of Finance? Under such constraints, HSR ends up being narrowly focused on the financing of health care services. It ignores the fact that financing (e.g., geographically targeting subsidies, the use of pre-payment plans***, of exemption mechanisms, of social insurance, of community-based prepayment plans) and non-financing approaches (e.g., incentives to staff****, better support supervision, working referral systems, increased diagnostic skills…) can be used to increase access and increase equality. These should be arguments enough to say that HSR is not an end in itself; it depends on who will ultimately benefit from it.
***: In pre-payment schemes on maternal and child care (MCH) money can be/is collected from women at the time of getting their marriage certificate registered.
****: These financial incentives to staff do not necessarily work! (The private approach, that we do not subscribe-to, is to motivate providers financially to meet targets or good scores as a pre-requisite to receive subsidies).
8. We need to know all this to be fully aware what we are moving towards to. For instance, care must be taken to prevent the central government washing its hands leaving everything to the local level, that is, shifting all financial responsibilities and constraints to the local level governments.
9. Sadly, there is a critical shortage of people who can translate a vision of HSR using a HR lens, i.e., people who are willing to take-on the issues at hand from a HR perspective. Training in-and-of-itself is not a panacea. Its biggest determinant of real success pertains to the attitude and the ideological stand of the trainers. This is why the right leadership is so important. Even one person can make an enormous difference. There is a need for new and innovative, on-the-job, HR-based training that includes healthcare management issues and includes needed support supervision.
10. Additionally, the needed HR focus empowers public interest civil society organizations and social movements seeking justice in health. But sadly, civil society is fragmented; it is little groups that are doing excellent work on a number of small aspects of the health sector’s problems; they need to coalesce and organize to influence the institutional process of HSR in the direction of the right to health and comprehensive PHC. HSR must absolutely be viewed as participatory work in progress, not as an end of itself. (Population Council)
11. Because of this fragmentation, there is no single monolithic ‘human rights community’ just as there is no unified ‘health and human rights community’ claiming these rights. (Alicia Yamin) Here is what has failed so far: The national implementation of international law seeks to translate HR law into public health realities, structuring fairness in health policy making and affording equal rights to all to access to health goods and services. In essence, the right to health seeks health justice for the many who have had neither health nor dignity. So, as public health activists, we promote participatory community health as the opportunity to touch another person in a way that conveys dignity. (Ron Briun)
How do we put health-policies-intended-for-prompt-action truly into the hands of claim holders everywhere?
12. Take, for instance a comprehensive PHC policy. Here are some key pertinent questions we ought to be (but are not) asking about such a policy:
13. What these questions highlight is that policy is not for policy makers alone. The latter meet in national and international conferences:
14. Repeat: Policy is thus not for policy makers alone. What is really needed is working out how we really put the PHC policy-for-action into the hands of ordinary women and men (…and children!). What kind of leadership that empowers claim holders will we need for that? Bottom line: How does all this connect with the stated PHC policy we envisioned to begin with, as per the paragraph above? As always, food for thought.
Claudio Schuftan, Ho Chi Minh City
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All Readers are available at www.claudioschuftan.com
Postscript/Marginalia
-Basically, health is valued as the most important attribute by people. It is an essential component of happiness. And we have come to this world to be happy… This makes us conscious about having to get rid of globalization’s ‘consumopathy’ that pushes us to use all our energies to ‘have things’. It gives us a new enthusiasm to address difficult, complex problems with a renewed creative imagination. It gives us new impetus to live with hope caring for health, for life every day of our existence. (Julio Monsalvo)
