Equity in health across the world: Neoliberalism or new welfare policies?
President: Marc Renaud (Canada), Giovanni Barro (Italy), Saul Franco (Colombia)
Name of the Group: International Association of Health Policy
The Perugia Declaration
New Welfare, Sustainable Development and World Government of Globalisation, for relaunching Equity and Health Promotion across the World.
10th IAHP International Conference on Equity and Health across the World: Neoliberalism or New Welfare State?., Perugia, Italy 23-26 September 1998
1. At the conclusion of the 10th IAHP International Conference on Equity and Health across the World: Neoliberalism or New Welfare State?, held in Perugia from 23 to 26 September 1998, the International Association of Health Policy- IAHP makes an appeal to those who are involved in the culture of innovation, with the aim to create a collaborative climate and a strong public opinion capable of influencing national, supranational and international decision-makers in order to safeguard and enhance the socio-political framework which is needed to face the problems of health in the World in the era of globalisation.
This appeal is addressed to single people, who seek a full range dialogue around the destiny of the Welfare State.
It is also addressed to representatives of thought and scientific schools and to everyone who is professionally involved in the study of interrelations between equity, health and health policies.
It is finally addressed to members of national, supranational and international organisations who want to exert an active presence at such levels in order to set out new orientations and goals for social security.
2. The data on the trends of health conditions across the world, published by WHO, portray an international framework where, along side some important successes, many severe steps backward are shown, which have damaged Equity even more at a world-wide level. Such data legitimise us to decree the substantial failure of many long-period health strategies, beginning with Health for all by year 2000, whose unhappy destiny is a link in the chain of other WHO welfare-inspired strategies, based on Primary Health Care (Conference of Alma Ata) and Health Promotion (Conferences of Ottawa, Adelaide, Ljubljana and Djakarta) since 1978.
These strategies have failed because the mechanism which was to assure a widespread development of economics at an international level stopped. After which, no financial margins to devote to the economically undeveloped countries for supporting the weakness of their economies could continue to be still guaranteed. In addition, the gradual imposition of Neoliberistic responses and the dismantlement of many Welfare state protections made the crisis even more acute, as so did the worsening of peace on the Planet, notwithstanding the hopes arisen after the end of the World’s division into two politically and militarily opposing blocks.
3. The 10th IAHP Conference has taken note of this scenario, confronting it with the global balance of the last two decades. It was a balance full of fears about the destiny of the Welfare state and Equity across the World: in fact important decisions were made during this time which deeply influenced the possibility for many people to have access to the measures undertaken for promoting and protecting the health of the population and more generally for keeping universality the landmark of the social security policy.
We are approaching the end of the 20th Century besieged by the risks to be expected if World economy and production continue to develop forgetting the interests and the fundamental rights of humanity: we fear indeed that this tendency, if not interrupted, will bring about the major decline of health across the world, even beyond what has already happened during the last quarter of the on-going Century. The horizon is also being obscured by the probability that under the domain of a �world government� led by the crude market laws, the distance will increase between people who can protect their health and people who cannot, namely between a minority of the Planet�s population and several billion women and men scattered over all the Continents.
This widening of inequalities is even more unacceptable when considering that the 20th Century is going to end with an extraordinarily positive balance as far as scientific knowledge is concerned; thanks to this, the theoretical possibilities of preventing the decline of health and to control ill-health by means of biomedical procedures and social measures have increased enormously. But obstacles, funnels and pitfalls are so far preventing the realisation of more than a part of this �achievable health�, with tremendous differences between areas of the Planet and inside each country.
4. Neoliberalism must be charged with a great responsibility for this balance. The 10th Conference demonstrated this, showing how life conditions are worsening all over the Planet: in established market economies and in the former Socialist countries; in the Latin-America continent as well as in other regions at the boundaries of wealth but where people live nearly without hopes of development; both in the Mediterranean Islamic countries and in other Asian areas beginning from such subcontinents such as India and China, down to Sub-Saharan Africa.
So as not to flatten the Planet�s conditions under a totally negative statement of the last twenty years, a general overview shows that the expectations of rationalising the World�s development by means of a market freed from regulations and unaware of the people�s vital interests, have not been met. Even where successes have been achieved, in the face of economic growth and production, this occurred without the possibility for everyone to enjoy them. The scissors between the wealthy classes and those who live under the threshold of poverty increased everywhere, even inside the countries with an established market economy.
The strategy of Neoliberalism, therefore, has brought and brings real high risks of definitely loosing the great values of universalism, equity, freedom from need, justice, solidarity, stated by the Constitution of UNO and reproduced in the Humanity�s Right Chart. The barriers and contrasts that have been erected everywhere against equal relationships between classes, races, gender, religious faith, and others, allow us to assess that beyond the globalisation of economy, Neoliberalism has also resulted in a process of globalisation of social inequities.
5. The analysis presented to the 10th IAHP Conference indicates that the decades from 1980 to the end of this Century have been characterised not only by the raise and fall of the counter-welfare policies following the Neoliberalist strategies, but also by the fall of the parabola of the post-war Welfare state, whose cycle had been opened after the end of World War Two, based upon the conviction that a progressive and unlimited enlargement of production could offer more employment and elicit enough resources to redistribute wealth among citizens. Such conditions did not survive for many reasons, not least the economic and financial crisis of the world system, which has reduced the sources with which to supply the welfare state, in addition to the severe and structural narrowing of salaried work.
6. As a part of this tendency of Neoliberalism and Welfare state we may also cite the crisis of the role of those international organisms whose action is fundamental for the destiny of health.
We cannot avoid expressing a severe criticism of the World Bank and the International Monetary Fund, two institutions which are crucial for financing development policies, for having submitted their support in favour of the disadvantaged areas to a strong reduction of public expenditures, to the dismantlement of many advanced social security protections and to a financial balance too quick to be compatible with investments on man, whose positive effects occur very slowly. A severe criticism must also be expressed even towards the World Trade Organisation because of its support to food production strategies not rarely in contrast with health interests, or at least ignoring them.
WHO itself has lived the last two decades squeezed by internal controversies who reflect the contradictions between its welfarian nature and the Neoliberistic tendencies adopted by most member-Countries. A contradiction aggravated by a progressive crises of legitimacy, after development of supranational structures (namely the European Union) that have little by little assumed a role of political subject, in addition and not rarely in competition with UNO and inevitably with WHO which is one of its agencies. Under this respect, it is not possible to keep under silence the links with the World Bank, which we hope will not be confirmed by the new WHO General Director.
7. The crisis of hegemony of Neoliberalism and the exhaustion of the propulsive pressure of post-war Welfare state demand a string reflection upon the perspectives.
First of all we must be aware that a return to the past time cannot be proposed nor is desirable.
Not least because we must face a future of limited resources, new horizons are needed to draw inside them the guide-lines of a sustainable development, that is a development no more centred on the quantitative growth of production, but based on dramatic changes in the economic, social and political paradigms. Indeed by “sustainable development” we mean a development which will not collide with the growth of economy but where some major pre-conditions will be established, the main of them being that the production (and the consumption) must be compatible with a finite quantity of resources together with the assumption that the population wealth is the first and final scope of the economic policies, so to safeguard both humankind dignity and their health conditions.
“Sustainable development” is the only way out from the world’s crisis of the end of the 20th Century because it implies political choices to eradicate egoism, that is one the roots of Neoliberalism, and to recover the inclusive goals already expressed by the UNO Human Development Report (1990) and the World Conference of Rio de Janeiro, not to remember that such a response is located at mid way between the nostalgia of unlimited growth epoch and the anti-historical receipts of zero growth.
Sustainable development bring to the surface the principles of universalism, equity and solidarity which are the essence of the welfare philosophy; it demands then to build a new Welfare state, by which to recover also consensus from the world population, where and when disappointed by the traditional Welfare state. Such a mission makes the welfare state not only possible but also necessary.
8. The new paradigm of development must take into account the globalisation in its two sides: globalisation of the problems and the globalisation of the strategies which are needed to face them. A domain, the last, not new but never so totally involving as now. In this framework it is necessary to plays the cards of a renewed solidarity agreement among all the Planet’s inhabitants, that is to say a new social contract, in short terms a new Welfare state.
The globalisation piloted by the market’s laws as it happened so far and is still happening is one of the source for worse conditions of equity, mainly in the underdeveloped regions. But globalisation is not limited to economics: processes of globalisation have occurred in other field, such as culture, training, education, information, scientific research, technological development, and other similar activities which have enlarged the panorama of the exchanges with even positive effects.
This is way next to sustainable development it is time to refer to a sustainable globalisation, which mean that we must assume an attitude of critical attention to a phenomenon which can be positive or negative, depending on where the levers of the power are kept. In particular such a phenomenon will have positive echoes if it will open to the claim of a “world government” capable to warrant the game-rules by which avert the risk to consign health and health services to an unregulated market, to for-profit competition, in short to “monetize” such goods as health which cannot (better: should not and will no more) be converted into monetary values.