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[afro-nets] Food for a subversive thought

Food for a subversive thought

Human Rights Reader 371


-In the words of a Dean of Johns Hopkins University, work in the health sector 
requires the flexibility of an earthworm, the ability of a locksmith and the 
capability of mounting a grand indignation of a lawyer. (…in Philadelphia  in 
the original quote).

1. The veritable crisis in health systems failure we see the world over should 
lead us to a re-think of the triumphalism that has marked some of the global 
health debate in recent years as the MDGs are evaluated. Some even project a 
‘grand convergence within a generation’ between North and South --rich and poor 
countries-- based upon predictions of ‘an end of preventable mortality, 
including that from infectious diseases’. The truth though is that health 
systems in too many countries are and have been dysfunctional --way before 
Ebola hit. (i) Health facilities are often a place where people, especially 
women and children, experience first-hand their poverty and marginalization. 

(i): Is ebola the terrorism of the poor…? (P. Farmer)

**The greatest attribute of health (and of the right to health) is to desire 
it.** (L. Weinstein)

-Yes, we desire universal health coverage. But what must we do when UHC means 
different things to different people? …and is not in line with human rights?

2. A question that remains ever unasked is whether the ‘communitization’ of 
health services in diverse contexts is the real desirable alternative to their 
privatization; it certainly is the mean to heighten and boost the ‘publicness’ 
of health services. (A. Shukla)

3. However, it is more. Not only do we not ask the preceding question but, as a 
corollary, we actually do not actively enough identify and use effective means 
to tackle the ‘commercial determinants’ of preventable ill-health, malnutrition 
and deaths. This, despite the fact that it is now increasingly recognized that 
the key political debates in public health revolve around countering the 
primacy of economic over social policies as a consequence of the reign of 
neoliberalism. (I. Kickbusch)

4. Current health systems, with their data collection and (little) use, their 
practices and their tools cannot just result-in and be satisfied-with coming up 
with yet more technical ‘recommendations’, ‘guidelines’ and ‘model programs’. 
Why? Because the subjects of health care delivery systems are people and 
communities with real every day problems, with needs and with desires anchored 
in very concrete contexts. Their problems cannot be dealt with 
numero-statistics used in tables and elegant figures that ‘describe’ and 
perhaps monitor trends in health situations. These statistics often only mask 
or scratch the surface of the real problems at hand. Little is done to ‘take 
charge’ of the latter to really address them in a truly disaggregated, 
participatory and human rights-based way. (G. Tognoni)

5. National health services said to be centered on primary health care have 
been ‘reorganized’ through waves of liberalization, privatization and 
disease-focused verticalization, as well as through performance-based financing 
and many other reforms. As a result, people have come to services to find new 
rules for what is free and what is charged, for what medicines and supplies are 
present and which are not. Furthermore, community health activities and 
community health workers have appeared, disappeared and appeared again.  The 
problem lies in the application of biased forms of knowledge that subdue 
others, in practice excluding and disempowering these others from the creative 
processes that have a much better chance to transform society.

6. What is really scary is that this also fosters the tendency for ordinary 
people to be the last to know and care about the waves upon waves of reforms 
transforming their health systems. Action cannot grow out of knowledge and 
options conceived in distant corridors.(ii) Those affected by the problem are 
the primary source of information and thus the primary actors that can truly 
generate, validate and use the knowledge needed for lasting, sustainable 
action(s). It is rather a problem when the knowledge used to guide this change 
does not draw on the experience, knowledge and wisdom of those directly 
involved, through methods that build their sovereign power to inform, to 
learn-from and to shape the needed changes.(iii) (R. Loewenson) This is why 
some of us are now speaking of health sovereignty (as in food sovereignty).

(ii): Knowledge tends to drive out wisdom.

(iii): Authoritarianism and obedience go together with an a-critic and rigid 
thinking; they also go together with disqualifying the weak and minorities; 
with stereotyping and prejudice; with a lack of tolerance that brings about 
permanent conflict between a spirit of service and the currently predominant 
mercantile mentality of so many health planners. (L.Weinstein)

**Human rights applied to health aim at personalizing subjects that are 
actively being made to be impersonal, i.e., at personalizing a population-level 
intervention.** (M. Debartolo)

7. Many of you have heard the call for Health in all Policies (HiaP) as a 
purported vehicle to fulfill the right to health and to achieve greater 
equality. It is centered in calling for greater ‘policy coherence’ --just 
otherwise defined. HiaP has a ring of the ancient call among us for a 
multisectoral approach only now insisting to give health a greater deserved 
attention.(iv) The question, of course, is which kind of health are we to more 
aggressively promote. It is no secret that in the world we are divided on this 
issue. There is a clear North/South gap; there is a gap between what we in 
public interest civil society want and what charter-based UN agencies want; a 
gap between what international NGOs and public interest CSOs and social 
movements want. Worrisome is the fact that each group will continue pushing 
their vision of which health and HiaP to promote. I am afraid we cannot sweep 
the politics of it all under the rug anymore. We cannot make progress when 
different breaks are on; we need full speed.

(iv): Being skeptical, I ask coherence for and between what? Public interest 
CSOs and social movements will continue to fight such coherence when just 
understood as multisectoral coordination without a call for structural reforms; 
they will lean towards approaches closer to those made in Brazil.

8. The collective social action needed for the right to health to be respected 
and fulfilled shows us that there are three types of mobilization: (a) the 
rejection of the imposition of health policies related to a neoliberal health 
system model that commoditizes health and privatizes the social security and 
health systems (e.g., Mexico, Colombia and Peru); (b) the active defense of 
public social security systems and of universal health care systems under 
threat by a commoditization and privatization drive (e.g., Brazil and Costa 
Rica) and (c) the autonomous proposition of communities resisting and 
generating their own forms of health care and of the protection of life (e.g., 
Chiapas in Mexico, Chimaltenango in Guatemala and Cochabamba in Bolivia). (M. 

**The challenge we face in health care reform thus is to set up a universal 
health system based on the human right to health.** (M. Rios)

9. Health sector reform has for long been a citizens demand because, in so many 
places, the current system has for practical purposes collapsed. The way the 
system is organized does not respond to the needs of people and, therefore, 
violates their rights. The challenge thus is to come up with a health system 
that, by building on human rights principles, addresses solemn international 
obligations and national promises, agreements and even constitutional mandates. 
Therefore, in the debates about health sector reform, it is no longer 
postponable to incorporate the following measures to unequivocally strengthen 
the role of the state:

o   in its health governance function (as relates to stricter and enforced 
health regulations);

o   in public health care financing (increasing the state’s share in the 
financial protection of the most vulnerable, increasing health expenditure to 
at least reach the average of the countries in the region);

o   in the delivery of health care services (improving health infrastructure 
networks including physical, personnel and equipment needs);

o   in truly implementing comprehensive primary health care services and 
securing referrals to secondary and tertiary care facilities according to need 
and not capacity to pay;

o   in guaranteeing quality of services (security in the services for patients, 
as well as for staff, protection of the rights of patients and of labor rights 
with clear recourse mechanisms to seek restitution when appropriate);

o   in setting up regular support supervision functions of the actual provision 
of services;

o   in enhancing the capacity of regulatory and supervisory structures to carry 
out their duty;

o   in respecting the binding character of participation and representation of 
claim holders that allows them to actively participate in the policy decision 
making process at the national, regional and local levels of government (with 
claim holder representation being 50%+1 in the lower decision making levels);

o   in respecting the participatory surveillance and monitoring role of claim 
holders in the delivery of health care services;

o   in bringing together and eventually unifying the different existing 
sub-systems of health care financing and health care delivery (as well as 
strengthening the capacities needed in each of these sub-systems so as to 
facilitate their evolution towards true complementarity);

o   in guaranteeing that financial and other resources are made available to 
make universal health coverage a reality for all (with those who have private 
or social health insurance schemes paying their premia in part subsidizing the 
state’s own funds allocated to those who cannot afford health care costs;

o   in curbing corruption;

o   in guaranteeing access to generic medicines;

o   in reinforcing the social security system aiming to reach the ILO’s 
recommendation of 12% of wage contributions to this function (includes 
democratizing the management of social protection services with meaningful 
workers’ participation and representation with a binding character);

o   in the state assuming the remuneration of the majority of professional and 
overall health staff;

o   in eliminating any bonuses paid out-of-pocket by patients;

o   in eliminating any barrier to access to health care based on any previous 
administrative or bureaucratic requirements that interfere with the fulfillment 
of the human right to health; (no citizen must die or her/his health and 
economic situation be aggravated by any perfectly treatable disease);

o   [in national human rights bodies closely monitoring the elimination of 
barriers and keeping vigilant about ministry of health decisions that endanger 
the fulfillment of the right to health especially when reform measures are 
regressive towards commoditizing the delivery of health services]. (M. Rios)

10. It is fitting to end this Reader by reminding us of Latinamerica’s ‘Five Ds 
in the Struggle for Health’. They are: Decolonize our thinking, Demedicalize 
life, Decommoditize health, Deindustrialize development and Dignify life. 

Claudio Schuftan, Ho Chi Minh City


-Now more than ever, we need more critical insights about the MDGs pertaining 
to health with their serious shortcomings, as well as the courage to apply 
human rights to health beyond them being a legal paradigm.

-Some top down ideas ought to begin at the bottom; then rise like the sun. (J. 

-Science and technology cannot put order in our lives; it is values that put 
order in our lives. (Albino Gomez)

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