London 2001 Conference abstracts: A. Stolkiner

Alicia Stolkiner and research team PT48 UBACyT

Research and Health Policies: including the social actors in research

Institution: Secretariat of Science and Technology of the Buenos Aires University
Address: Conde 665 (cp1426) Buenos Aires, Argentina.
Phone / Fax: (54-11) 4555-7365
E-mail

Introduction

I am grateful for this opportunity to participate in this meeting with you. The question that brings us together � is there any possibility of developing and supporting public health care in a neo-liberal environment? — is central to any research in the field of health and is the heart of any study dealing with the Reform of the sector.

The objective of this presentation is to share with you some thoughts about problems that are inherent to research in the area of health. To do this I will focus on three main questions: the delimitation of the field of research in health, the inclusion of the actors in the investigation process and the reflexivity exercised upon the practice of research in this area.

This proposal arises from a work carried out during six years by an interdisciplinary research team, of which I was the director and which was formed through an agreement between an academic unit (the University of Buenos Aires, Argentina) and a health care service provider (the SAMIC-Eldorado Hospital, in the Province of Misiones). The team included staff members of both institutions .

The group analyzed the impact of the transformation of health care services in the health-disease process in a small border town. The purpose was to assess the unique effects of the reform on small units, without the usual dissociation between a macrosocial and microsocial analysis. The study also included health care workers in order to identify the tools that would facilitate their development as social actors in the transformations in course.

Different levels of analysis were used: firstly, the transformation of the State and the Reform of the Health Care Sector in Argentina to set the contextual framework, then, the particular manner in which the Reform was implemented in the Province of Misiones and finally, a specific assessment of the effects of the transformation in a small border town Municipality. Our aim was to shape and to express the discourse and characteristics of the two key potential actors: workers and users of Health Care Centers.

The methodology combined quantitative and qualitative data production techniques. It included surveys, documentation and interviews. Following research tendencies in health systems and services, the study aims to relate the academic activity to political decisions about sectorial policies. But the core of the methodology was the participation of the health workers included in the research team. The participation of these health workers in the research process favored their empowerment as actors that produced political effects at local level.

The partial results of the research were presented at the last IAHP- Europe meeting in Barcelona ( Stolkiner y otros, 1999) and they show tendencies confirmed in the final field research.

Final results show deep transformations in the uses of the services by poor users and in the performance of the sector workers. These transformations imply changes in practices and social representations. There is a great gap between the statements of the reform, and what happens in the daily lives of the poor. When accessibility barriers increase, poor users develop alternative care strategies, but tend to abandon previously acquired service user habits and in some cases even accept death without medical assistance as the natural destiny of their lives. (Barcala y Stolkiner, 2000). Besides, the practices and ways of participation of the sector workers are also modified ( Contreras A. y Radunski P, 2000).The small unit that was studied shows the effects of an extreme use of mercantile logic in an area that is irrelevant as a market. The attempt to have a financially self-sufficient Hospital and to eliminate Government funding, dismantled all types of primary care, the most necessary one given the population profile in the area.

The last ten years of State reform in Argentina seem to indicate that the development of public health, even just the conservation of public health appears to be impossible within this context. But our experience does not necessarily have to be yours. Inspite of this it is good to remember that , as I said in Barcelona, our experience can be a paradigmatic example for you.

An example of what happens when the forces of civil society are weak and democracy can not limit the voracity of financial power and the national economic power groups related with it. The major interest of the most powerful actors in the Argentine health system reform is not the people�s health. The fundamental principles of the adopted reform are foreign to the health-disease process of the population. It should be noted that some of the main motivators behind all this are based on the needs of the economic model: to ensure an equilibrium in government accounts, making them independent of health care costs, to reduce labour costs and to generate investment opportunities for international investors (Gonzalez García, G. and Tobar F.; 1997).

As Mario Borini (1996) wrote, the key objective of the process is to legitimize the appropriation of the surplus that the health care funds could generate. The goal is to have less expenditure than financing as a means to legitimize the profits of the banks and insurance companies. It is the author’s opinion that the ultimate goal is an extreme financial logic (at the expense of private hospitals and mainly professional medical fees) to legitimize the appropriation phenomenon. The competition, in which all the subsectors would be involved, including state-owned hospitals would be a function of the goal to reduce costs and allow a surplus production.

In spite of this situation, at decision levels and in the academic world, the discussion tends to focus on technical and administrative issues. The adoption of innovative management and marketing techniques, quality control standards, etc., have replaced the profound analysis and a realistic assessment of the future for the health care system. Inasmuch as the goals of the transformation are external to the system, a double discourse is generated. It seems that researchers must serve this logic without being critical of it or they will be accused of being �ideologists� without any practical proposals.

We are therefore obliged as researchers to ask ourselves, first of all, what is and what should be our role in this process and the definition of this role will necessarily determine the choice of research strategies. As Alvesson and Sköldberg (2000) wrote �it is not methods but ontology and epistemology which are the determinants of good social science�.

1 The Field of Research in Health. Some Reflections on its Configuration.

As Bourdieu says the incorporation of the concept of field means thinking in relational terms. A field can be defined as a network of objective relations among positions. These positions define themselves objectively by their existence, by both the decisions they impose upon the occupants � the agents or institutions � because of their current and potential location (situs) within the distribution structure of the different kinds of power or capital, the possession of which implies access to the specific earnings that are at stake within the field and finally by their objective relations with the rest of the positions. (Bourdieu P. and Wacquant L. , 1995, pg. 64).

The field of health research appears at an intersection between the specifics of the field of health and the field of science and technology production . This point of intersection implies that its actors and institutions bring together determinations inherent to the health sector on one hand and to the domain of scientific and technological production on the other. Both areas have undergone major transformations directly related to the transformations that have taken place in the relations among State, Market and Society within the framework of the neo-liberal models.

A characteristic of this field of research is that it does not depend heavily on the traditional academic world. Industries, international agencies and organizations, governments and academic entities all participate in it.

Considered globally, the field of biomedicine and technology is the one that probably receives the largest amount of funding, being highly dependent on the interests of the industries involved . During the last decades the chemical-pharmaceutical industry�s needs to increase their competitiveness have led it to invest heavily in research and on some occasions to break ethical codes. It is estimated that laboratories must launch two o three products a year capable of generating sales of over one billion dollars just to stay in the world markets (Bouguerra, M.L. , 2001). The recent legal battles between the South African government and the important laboratories over the cost of AIDS medication is an emerging sign of the times and perhaps even a political one to be kept in mind. They clearly demonstrate the antagonism that exists between the interests in profits and the right to life.

Research into health systems and services or into health policy does not have such a direct link to the market. Its origin is more tied to health policies within the framework of the so-called Social States and to the Latin American developmentalist proposals. The fact that it is linked to states makes it vulnerable to the vicissitudes suffered by these. Although international organizations have been insisting on the need for the development and promotion of this kind of studies for the last two decades, the gap between what is investigated and the need to develop and improve the people�s health is not closing.

A document published by the Council for Health Research makes a quick situational diagnosis and states: ” No more than ten percent of global spending on Health research is devoted to solving the main health problems of the poor… even in countries with a disproportionately high burden of disease the national research effort may not be directed at pressing problems but may be driven by the profit motives of the private sector, the curiosity of researchers or the particular agendas of donor agencies” ( COHRED, 2000- p.2).

What seems to worry those in charge of developing this area is how to make research directly influence the taking of both decisions and action in health, that is to say, the policy making. The debate revolves around the question of how to develop the capacity of effective research (capacity building) and how to involve the policy makers in the results.

I will not stop to discuss this question now but rather to consider what it omits: the determinations that operate in this field of the production of knowledge and its agents. Given the struggle to obtain funding for research, the existence of hegemonic languages and methodological models in the area of health policy research determines the production of knowledge. These, in turn, determine the investigator�s position in this complex institutional world.

The agencies and institutions upon which research depends are also subjected to the same transformations as those that affect the field of health. In analyzing the Brazilian scientific – technological production agencies, Mario Hamilton declares: ” The logic that precedes the realization of scientific activities is influenced by both the widest macro ” institutional context in which they are immersed and by the way the changes in this environment affect the “values” that precede the realization of such scientific activities. Among the principle stimuli affecting this process, the following factors can be highlighted:

  1. changes in public policies that tend to stimulate both the commercialization of the generated technologies and the practical application of knowledge that has been developed
  2. demands from the macro – environment requiring an adaptation in the orientation of scientific activities towards more intense competition
  3. the growing need for scientific institutions to search for alternative sources of research funding due to the decline from traditional public sources”.(Hamilton, M., 2000).

The collapse of the barriers separating private interests and the State, in terms of research, necessarily produces modifications in the values and representations that are the foundation of scientific activity.

For example, the elaboration of indicators and tools for evaluation and management carries an undeniable ideological and political load. A recent article by Vicente Navarro in which he analyses the WHO World Health Report is an excellent exercise in deconstruction, which criticizes suppositions and ideological values used to support the construction of the tool which was, in turn used to produce the same report that assessed the world�s health � care systems based on an overall index of performance (Navarro, 2000).

Although it may be obvious, we must remember that the researchers depend on these vicissitudes for their subsistence and for their recognition . In a recent debate about Health Systems and Services Research Susana Belmartino wrote: ��researchers must be aware that it is a scientific � technical function being exercised within the context of a strong political struggle among social organization models in conflict, and intensified by a demand for financial resources which thoroughly exceeds available supply�� (Belmartino,S., 2001). I do not agree with the definition of �scientific � technical� function for research but I do agree with the statement that �researcher must be aware�. This then, takes us into the subject of reflexivity in the research process.

Reflexivity and critical research

Given the fact that health research is strongly related to practices and their applications, it paradoxically requires a greater epistemological vigilance. This implies always being aware of the determinations and forces that act upon the process of the production of knowledge.

For Alvesson and Skoldberg (2000) a reflective approach means that…�due attention is paid to interpretive, political and rhetorical nature of empirical research. This in turn calls for an awareness among researchers of a broad range of insights : into interpretive acts, into the political, ideological and ethical issues of the social sciences and into their own construction of the �data� or empirical material� . A reflexive approximation implies recognizing oneself in the place one occupies within a specific field. This place is not neutral, is not external and does not stop producing effects.

For example, the fact that the institutional mainstay for our research was a Public University gave us some freedom in the choice of theoretical frameworks and strategies. We are aware of the fact that this freedom tends to diminish when the place of universities is questioned and attacked.

We also decided to include primary level of attention workers as team researchers because we considered that within this reform process they remained objectively linked to the health requirements of the most needy populations. There was a very strong relation between their necessities and demands and those of the population although there continue to be some differences. With their incorporation as participants and valid speakers, we counterbalanced the academic tendency and transferred tools for action into their hands. In fact, we also questioned the traditional concept of scientific objectivity.

This, in turn, was the result of an adopted ideological position; that the investigation had to place two silent actors of the reform process on the stage of events: the primary level workers and the poor users of the sector. Special consideration was also given to the organizations within civilian society that act in the area of health.

Regarding the inclusion of the users, we decided to select a particular group � the poor � and to recuperate as part of the study�s micro and psychosocial dimension their experiences, discourses and strategies. This level of analysis turned out to be indispensable for the emergence of some unexpected results.

It would seem that the weak voice of the users in the reform process is not just a local characteristic. A recent text by Richard Saltmann (2000) states that …� The reform of the Health Sector in Europe during the 90�s has made a great variety of subjects and actors appear. The institutions that provide services, the health sector professionals, the public and private payers and the public authorities, all of them have witnessed the important changes in their roles and responsibilities. The actor whose relation with the health system has least changed, as strange as it may seem, has been the patient.� He concludes by saying that patients are still more objects than subjects with respect to the health service systems.

But this quality and characteristic of being an object is precisely how the patients are represented in the logic of the service providers and is many times adopted acritically by researchers in their methodologies. In the micro and psychosocial dimension of our research the users showed themselves as subjects of great vitality but having a low capacity of impact upon the decision � taking level. This poor population that had had access to free state health services and that had actively participated in a successful primary attention health program � later dismantled by the reform � developed health care strategies which are basic in all rational use of health services. They had a spontaneous tendency towards preventive practices if they were offered the adequate information, they did not practice self-medication with industrial drugs (a frequent habit among Argentine middle class sectors) and within the process of attention they especially valued the doctor�patient relationship very highly, far more than the use of devices and medication. They also established informal community health care networks. The downside of the matter is that when they were prevented from using the services they acted with resignation : the idea of social rights was not installed among them (Barcala and Stolkiner, 2001).

Just like the term `population´, the category of �user�, which is created by the service sector, is an amorphous unit that quickly breaks down into different groups and associations as soon as it is analyzed. �Macro� research tends to consider the users as a unit and passes directly from this undifferentiated collective grouping to the individuals themselves and their behavior. They are frequently omitted as possible actors except to consider their individual behaviors. The opposite of this would be to��overcome the interpretation of the user as an individual-patient-carrier requiring attention and build a new relational perspective that would link the service organization with the needs, expectations and demands of the population under its charge. This would imply incorporating the dimension of groups or social units and refers to ways of organizing demand that could incorporate a political dimension.� (Belmartino, 2001-pg40).

One of the effects that our research work had was to promote a demand for primary health action within the community and this proposal was inevitably taken up by some possibly influential actors. It also strengthened the political strategies of the health worker sector.

CONCLUSIONS

The first step that must be taken to assure that research has an influence on policies and decisions would be to recognize the political nature of all research processes. This implies that the investigators must firstly reflect upon their own position as actors, both in the field in which they do their research and in the field of research itself.

Within the field of research itself, it is a matter of finding collective and social ways of defending the autonomy in the production of learning and knowledge. Nowadays ,research institutions are obliged to submit to market logic as must the health sector. This determines both the possible limits for thought and the influence upon its values.

We must recognize ourselves as actors of our institutions (universities, agencies, etc.) so as to build and defend spaces for counter-hegemonic thought. In Latin America there are extreme cases of social movements made up of people excluded from the system that create or develop their own knowledge producing institutions and centers. This is the case of the Universidad de los Sin Tierra (University of the Landless Ones) in Brazil or of the recent founding of their own university by a faction of the Madres de Plaza de Mayo (The Mothers of May Square).

This is one more emerging factor in the configuration of a globalized pole of groups that defend rights � among them the right to health and to live � and that do not accept being subordinated to the needs of financial capitals. In our countries this antagonism is more evident but in essence it is universal.

Furthermore, any research done in the area of health policies and services requires adopting a position with respect to the actors in that field. We must formulate the questions and the problems from the point of view and understanding the logic of those actors whose interests are objectively bound to the health of the general populations and to the defense of the right to life. The establishment of a knowledge production alliance with these actors fortifies the research processes and simultaneously strengthens their actions. To do this, the research process must necessarily conserve their nature as subjects methodologically intact, that is to say, they must not be objectivized.

All of this does not mean forsaking technical and methodological rigor in research. It simply means abandoning the idea of research done from a neutral site because it is carried out in fields that are basically built upon antagonism and conflict. The question is to favor the redistribution of the symbolic capital, in contrast to the growing tendency towards the concentration of capital and wealth.
Meetings such as these can be part of the fulfillment of this objective.

Bibliography

Alvesson M.& Sköldberg (2000) : �Reflexive methodology- New Vistas for Qualitative Research� SAGE Publications, London.

Borini, M.(1996): “Reforma Sanitaria Argentina: ¿ Cómo se crea un nuevo excedente para una apropiación legalizada?”. Revista Salud Problema y Debate, año VIII, Número 14, Buenos Aires.

Bouguerra M. L.(2001) : En la jungla Farmacéutica Le Monde Diplomatique, año II, No 21, Marzo de 2001.Buenos Aires.

Barcala A. y Stolkiner A. (2001) : “Accesibilidad a Servicios de Salud de Familias con necesidades Básicas Insatisfechas: estudio de caso” VII Anuario de Investigaciones de la Facultad de Psicología- Universidad de Buenos Aires (en edición)

Belmartino S. (2001) : “Redefiniciones posibles en la investigación en sistemas y servicios de salud” Cuadernos para discusión No 1- Red de Investigación en Sistemas Y servicios de Salud del Cono Sud. Rio de Janeiro.2001

Council of Health Research and Development-COHRED (2000) : “The ENHR Handbook- a guide to Essential National Health Researh” , Switzerland.

Contreras A. y Radunski P.(2000) : “Reforma en Salud y Subjetividad de los trabajadores de primer nivel de atención en Eldorado, Misiones” VII Anuario de Investigaciones de la Facultad de Psicología- Universidad de Buenos Aires (en edición).

Cuadernos para La Discusión No 1 – Red de Investigación en Sistemas y Servicios de Salud del Cono Sur. Marzo de 2001. ( in internet:www.bireme.br./bvs/equidad/cuadernos1.pdf)

González García, G y Tobar, F (1997): Más salud por el mismo dinero. La reforma del Sistema de Salud en Argentina, ISALUD, Buenos Aires.

Hamilton, M (2000) : “Análisis Estratégico de Instituciones de Ciencia y Tecnología en Salud: una propuesta metodológica” Cuadernos Médico Sociales No 78. Noviembre de 2000, Rosario

Navarro V. (2000) : “Assessment of the World Health Report 2000” Lancet 2000; 356: 1598-601

Saltman Richard B (2000): “Dimensiones de la Participación Ciudadana en la Atención en Salud” ,Escuela de Salud Pública de la Universidad Emory. Informando & Reformando, Boletín trimestral del NAADIR. Octubre/Diciembre 2000

Stolkiner A. y otros (1999) : “Neoliberalism and Health Services in Argentina: a case study” Barcelona, España, Mayo de 1999. 11 INTERNATIONAL CONFERENCE – International Association of Health Policy- EUROPE

Human Right to Health, by David Werner

David Werner
Insuring the necessary resources for the human right to health: national and international measures

Address to the Global Assembly on “Advancing the Human Right to Health”
Iowa City, Iowa, April 20-22, 2001

In the 1940s, the United Nations declared Health a Basic Human Right. The World Health Organization was created to help make that Right a reality. But during the next several decades, the Right to Health remained a distant dream for most of the world’s people.

True, great advances were realized in medical science. The Western medical model, with its urban “Disease Palaces,” costly doctors, and commercial pharmaceuticals, was extended into the Third World. But to a large extent, the benefits of Western medicine remained inaccessible to the poor majority living in rural areas and growing city slums.

During the same period (from the 1950s through the 70s), important public health measures to reduce infectious diseases were introduced through national and international campaigns. But, once again, these measures were unequally distributed. Millions of children continued to die from diseases that could have been prevented through clean water, immunization, and good nutrition.

It became clear that poverty and powerlessness were the underlying causes of poor health and early death.

In pursuit of Health for All

Hopes for a breakthrough emerged with the Alma Ata Declaration in 1978. The world’s nations endorsed the goal of “Health for All by the Year 2000,” to be approached through a comprehensive strategy called Primary Health Care. The Declaration not only advocated universal coverage of basic health services, but also called for a “new economic order” to assure that all people could have a standard of living conducive to health. To achieve greater equity in meeting health needs, it called for strong popular participation.

At that time there was lots of optimism. But the year 2000 has come and gone. And today the dream of Health for All seems more distant than ever. A reversal has occured of many advances made in earlier decades. The Third World has seen a resurgence of “diseases of squalor” such as cholera, malaria, tuberculosis, and even plague. New diseases such as AIDS are taking their highest toll in populations whose basic needs and rights remain grievously unmet.

Why is it that the Human Right to Health still remains so far from being realized? What are the necessary resources and prerequisites for this Right to be implemented? And what are the limiting factors?

The World Bank’s “investment in health”

The World Bank — the newest and strongest player in international health — tells us that the key obstacles to approaching Health for All are economic. It points to the poor “cost-effectiveness” of Third World economies and specifically, of their health systems.

The World Bank has a very market-oriented concept of human health. It argues that good health is necessary for economic growth, and vice versa. The Bank’s 1993 publication, “Investing in Health,” advances a master plan for making health care cost-effective. (in terms of keeping a country’s workforce free enough from illnesses to contribute maximally to economic growth). To figure out which health measures merit public support, the Bank invented DALYs, or “Disability Adjusted Life Years.” It calculates how many DALYs can be saved by different interventions. In this scheme, the people of highest value are young adults, who are thought to work hardest. Infants, old people, and disabled persons have less value because they contribute little or nothing to the national economy; therefore they merit less public expenditure for their health (see Figure 1).

People’s Charter for Health / People’s Health Assembly

People’s Health Assembly
4-8 December 2000 in Bangladesh

Introduction

In 1978, at the Alma-Ata Conference, ministers from 134 members countries in association with WHO and UNICEF declared “Health for All by the Year 2000” selecting Primary Health Care as the best tool to achieve it.

Unfortunately, that dream never came true. The health status of Third world populations has not improved. In many cases it has deteriorated further. Currently we are facing a global health crisis, characterized by growing inequalities within and between countries. New threats to health are continually emerging. This is compounded by negative forces of globalisation which prevent the equitable distribution of resources with regard to the health of people and especially that of the poor.

Within the health sector, failure to implement the principles of primary health care, as originally conceived in Alma-Ata, has significantly aggravated the global health crisis. Governments and the international bodies are fully responsible for this failure.

It has now become essential to build up a concerted international effort to put the goals of Health for All to its rightful place on the development agenda. Genuine, people-centred initiatives must therefore be strengthened in order to increase pressure on decision-makers, governments and the private sector to ensure that the vision of Alma-Ata becomes a reality.

Several international organizations and civil society movements, NGOs and women’s groups decided to work together towards this objective. This group together with others committed to the principles of primary health care and people’s perspectives organised the “People’s Health Assembly” which took place from 4-8 December 2000 in Bangladesh, at Savar, on the campus of the Gonoshasthaya Kendra or GK (People’s Health Centre).

1453 participants from 92 countries came to the Assembly which was the culmination of eighteen months of preparatory action around the globe. The preparatory process elicited unprecedented enthusiasm and participation of a broad cross section of people who have been involved in thousands of village meetings, district level workshops and national gatherings.

The Plenary Sessions at the Assembly covered five main themes: Health, Life and Well-Being; Inequality, Poverty and Health; Health Care and Health Services; Environment and Survival; and The Ways Forward. People from all over the world presented testimonies of deprivation and service failure as well as those of successful people’s initiatives and organisation. Over a hundred concurrent sessions made it possible for participants to share and discuss in greater detail different aspects of the major themes and give voice to their specific experiences and concerns. The five days event gave participants the space to express themselves in their own idiom. They put forward the failures of their respective governments and international organisations and decided to fight together so that health and equitable development become top priorities in the policy makers agendas at the local, national and international levels.

Having reviewed their problems and difficulties and shared their experiences, they have formulated and finally endorsed the People’s Charter for Health. The Charter from now on will be the common tool of a worldwide citizen’s movement committed to make the Alma-Ata dream a reality. We encourage and invite everyone who shares our concerns and aims to join us by endorsing the Charter.

People’s Charter for Health

Preamble

Health is a social, economic and political issue and above all a fundamental human right. Inequality, poverty, exploitation, violence and injustice are at the root of ill-health and the deaths of poor and marginalised people. Health for all means that powerful interests have to be challenged, that globalisation has to be opposed, and that political and economic priorities have to be drastically changed.

This Charter builds on perspectives of people whose voices have rarely been heard before, if at all. It encourages people to develop their own solutions and to hold accountable local authorities, national governments, international organisations and corporations.

Vision

Equity, ecologically-sustainable development and peace are at the heart of our vision of a better world – a world in which a healthy life for all is a reality; a world that respects, appreciates and celebrates all life and diversity; a world that enables the flowering of people’s talents and abilities to enrich each other; a world in which people’s voices guide the decisions that shape our lives.

There are more than enough resources to achieve this vision.

The HEALTH Crisis

“Illness and death every day anger us. Not because there are people who get sick or because there are people who die. We are angry because many illnesses and deaths have their roots in the economic and social policies that are imposed on us.”
(A voice from Central America)

In recent decades, economic changes world-wide have profoundly affected people’s health and their access to health care and other social services.

Despite unprecedented levels of wealth in the world, poverty and hunger are increasing. The gap between rich and poor nations has widened, as have inequalities within countries, between social classes, between men and women and between young and old.

A large proportion of the world’s population still lacks access to food, education, safe drinking water, sanitation, shelter, land and its resources, employment and health care services. Discrimination continues to prevail. It affects both the occurrence of disease and access to health care.

The planet’s natural resources are being depleted at an alarming rate. The resulting degradation of the environment threatens everyone’s health, especially the health of the poor. There has been an upsurge of new conflicts while weapons of mass destruction still pose a grave threat.

The world’s resources are increasingly concentrated in the hands of a few who strive to maximise their private profit. Neoliberal political and economic policies are made by a small group of powerful governments, and by international institutions such as the World Bank, the International Monetary Fund and the World Trade Organisation. These policies, together with the unregulated activities of transnational corporations, have had severe effects on the lives and livelihoods, health and well-being of people in both North and South.

Public services are not fulfilling people’s needs, not least because they have deteriorated as a result of cuts in governments’ social budgets. Health services have become less accessible, more unevenly distributed and more inappropriate.

Privatisation threatens to undermine access to health care still further and to compromise the essential principle of equity. The persistence of preventable ill health, the resurgence of diseases such as tuberculosis and malaria, and the emergence and spread of new diseases such as HIV/AIDS are a stark reminder of our world’s lack of commitment to principles of equity and justice.

Principles of the People’s Charter for Health

The attainment of the highest possible level of health and well-being is a fundamental human right, regardless of a person’s colour, ethnic background, religion, gender, age, abilities, sexual orientation or class.

The principles of universal, comprehensive Primary Health Care (PHC), envisioned in the 1978 Alma Ata Declaration, should be the basis for formulating policies related to health. Now more than ever an equitable, participatory and intersectoral approach to health and health care is needed.

Governments have a fundamental responsibility to ensure universal access to quality health care, education and other social services according to people’s needs, not according to their ability to pay.

The participation of people and people’s organisations is essential to the formulation, implementation and evaluation of all health and social policies and programmes.

Health is primarily determined by the political, economic, social and physical environment and should, along with equity and sustainable development, be a top priority in local, national and international policy-making.

A call for Action

To combat the global health crisis, we need to take action at all levels – individual, community, national, regional and global – and in all sectors. The demands presented below provide a basis for action.

Health As A Human Right

Health is a reflection of a society’s commitment to equity and justice. Health and human rights should prevail over economic and political concerns.

This Charter calls on people of the world to:

Support all attempts to implement the right to health.

Demand that governments and international organisations reformulate, implement and enforce policies and practices which respect the right to health.

Build broad-based popular movements to pressure governments to incorporate health and human rights into national constitutions and legislation.

Fight the exploitation of people’s health needs for purposes of profit.

Tackling the broader determinants of health

Economic challenges

The economy has a profound influence on people’s health. Economic policies that prioritise equity, health and social well-being can improve the health of the people as well as the economy.

Political, financial, agricultural and industrial policies which respond primarily to capitalist needs, imposed by national governments and international organisations, alienate people from their lives and livelihoods. The processes of economic globalisation and liberalisation have increased inequalities between and within nations.

Many countries of the world and especially the most powerful ones are using their resources, including economic sanctions and military interventions, to consolidate and expand their positions, with devastating effects on people’s lives.

This Charter calls on people of the world to:

Demand radical transformation of the World Trade Organisation and the global trading system so that it ceases to violate social, environmental, economic and health rights of people and begins to discriminate positively in favour of countries of the South. In particular, such transformation must include intellectual property regimens such as patents and the Trade Related aspects of Intellectual Property Rights (TRIPS) agreement.

Demand the cancellation of Third World debt.

Demand radical transformation of the World Bank and International Monetary Fund so that these institutions reflect and actively promote the rights and interests of developing countries.

Demand effective regulation to ensure that TNCs do not have negative effects on people’s health, exploit their workforce, degrade the environment or impinge on national sovereignty.

Ensure that governments implement agricultural policies attuned to people’s needs and not to the demands of the market, thereby guaranteeing food security and equitable access to food.

Demand that national governments act to protect public health rights in intellectual property laws.

Demand the control and taxation of speculative international capital flows.

Insist that all economic policies be subject to health, equity, gender and environmental impact assessments and include enforceable regulatory measures to ensure compliance.

Challenge growth-centred economic theories and replace them with alternatives that create humane and sustainable societies. Economic theories should recognise environmental constraints, the fundamental importance of equity and health, and the contribution of unpaid labour, especially the unrecognised work of women.

Social and political challenges

Comprehensive social policies have positive effects on people’s lives and livelihoods. Economic globalisation and privatisation have profoundly disrupted communities, families and cultures. Women are essential to sustaining the social fabric of societies everywhere, yet their basic needs are often ignored or denied, and their rights and persons violated.

Public institutions have been undermined and weakened. Many of their responsibilities have been transferred to the private sector, particularly corporations, or to other national and international institutions, which are rarely accountable to the people. Furthermore, the power of political parties and trade unions has been severely curtailed, while conservative and fundamentalist forces are on the rise. Participatory democracy in political organisations and civic structures should thrive. There is an urgent need to foster and ensure transparency and accountability.

This Charter calls on people of the world to:

Demand and support the development and implementation of comprehensive social policies with full participation of people.

Ensure that all women and all men have equal rights to work, livelihoods, to freedom of expression, to political participation, to exercise religious choice, to education and to freedom from violence.

Pressure governments to introduce and enforce legislation to protect and promote the physical, mental and spiritual health and human rights of marginalised groups.

Demand that education and health are placed at the top of the political agenda. This calls for free and compulsory quality education for all children and adults, particularly girl children and women, and for quality early childhood education and care.

Demand that the activities of public institutions, such as child care services, food distribution systems, and housing provisions, benefit the health of individuals and communities.

Condemn and seek the reversal of any policies, which result in the forced displacement of people from their lands, homes or jobs.

Oppose fundamentalist forces that threaten the rights and liberties of individuals, particularly the lives of women, children and minorities.

Oppose sex tourism and the global traffic of women and children.

Environmental challenges

Water and air pollution, rapid climate change, ozone layer depletion, nuclear energy and waste, toxic chemicals and pesticides, loss of biodiversity, deforestation and soil erosion have far-reaching effects on people’s health. The root causes of this destruction include the unsustainable exploitation of natural resources, the absence of a long-term holistic vision, the spread of individualistic and profit-maximising behaviours, and over-consumption by the rich. This destruction must be confronted and reversed immediately and effectively.

This Charter calls on people of the world to:

Hold transnational and national corporations, public institutions and the military accountable for their destructive and hazardous activities that impact on the environment and people’s health.

Demand that all development projects be evaluated against health and environmental criteria and that caution and restraint be applied whenever technologies or policies pose potential threats to health and the environment (the precautionary principle).

Demand that governments rapidly commit themselves to reductions of greenhouse gases from their own territories far stricter than those set out in the international climate change agreement, without resorting to hazardous or inappropriate technologies and practices.

Oppose the shifting of hazardous industries and toxic and radioactive waste to poorer countries and marginalised communities and encourage solutions that minimise waste production.

Reduce over-consumption and non-sustainable lifestyles – both in the North and the South. Pressure wealthy industrialised countries to reduce their consumption and pollution by 90 per cent.

Demand measures to ensure occupational health and safety, including worker-centred monitoring of working conditions.

Demand measures to prevent accidents and injuries in the workplace, the community and in homes.

Reject patents on life and oppose bio-piracy of traditional and indigenous knowledge and resources.

Develop people-centred, community-based indicators of environmental and social progress, and to press for the development and adoption of regular audits that measure environmental degradation and the health status of the population.

War, violence and conflict

War, violence and conflict devastate communities and destroy human dignity. They have a severe impact on the physical and mental health of their members, especially women and children. Increased arms procurement and an aggressive and corrupt international arms trade undermine social, political and economic stability and the allocation of resources to the social sector.

This Charter calls on people of the world to:

Support campaigns and movements for peace and disarmament.

Support campaigns against aggression, and the research, production, testing and use of weapons of mass destruction and other arms, including all types of landmines.

Support people’s initiatives to achieve a just and lasting peace, especially in countries with experiences of civil war and genocide.

Condemn the use of child soldiers, and the abuse and rape, torture and killing of women and children.

Demand the end of military occupation as one of the most destructive tools to human dignity.

Oppose the militarisation of humanitarian relief interventions.

Demand the radical transformation of the UN Security Council so that it functions democratically.

Demand that the United Nations and individual states end all kinds of sanctions used as an instrument of aggression which can damage the health of civilian populations.

Encourage independent, people-based initiatives to declare neighbourhoods, communities and cities areas of peace and zones free of weapons.

Support actions and campaigns for the prevention and reduction of aggressive and violent behaviour, especially in men, and the fostering of peaceful coexistence.

A PEOPLE-Centered HEALTH SECTOR

This Charter calls for the provision of universal and comprehensive primary health care, irrespective of people’s ability to pay. Health services must be democratic and accountable with sufficient resources to achieve this.

This Charter calls on people of the world to:

Oppose international and national policies that privatise health care and turn it into a commodity.

Demand that governments promote, finance and provide comprehensive Primary Health Care as the most effective way of addressing health problems and organising public health services so as to ensure free and universal access.

Pressure governments to adopt, implement and enforce national health and drug policies.

Demand that governments oppose the privatisation of public health services and ensure effective regulation of the private medical sector, including charitable and NGO medical services.

Demand a radical transformation of the World Health Organization (WHO) so that it responds to health challenges in a manner which benefits the poor, avoids vertical approaches, ensures intersectoral work, involves people’s organisations in the World Health Assembly, and ensures independence from corporate interests.

Promote, support and engage in actions that encourage people’s power and control in decision-making in health at all levels, including patient and consumer rights.

Support, recognise and promote traditional and holistic healing systems and practitioners and their integration into Primary Health Care.

Demand changes in the training of health personnel so that they become more problem-oriented and practice-based, understand better the impact of global issues in their communities, and are encouraged to work with and respect the community and its diversities.

Demystify medical and health technologies (including medicines) and demand that they be subordinated to the health needs of the people.

Demand that research in health, including genetic research and the development of medicines and reproductive technologies, is carried out in a participatory, needs-based manner by accountable institutions. It should be people- and public health-oriented, respecting universal ethical principles.

Support people’s rights to reproductive and sexual self-determination and oppose all coercive measures in population and family planning policies. This support includes the right to the full range of safe and effective methods of fertility regulation.

People’s participation for a healthy world

Strong people’s organisations and movements are fundamental to more democratic, transparent and accountable decision-making processes. It is essential that people’s civil, political, economic, social and cultural rights are ensured. While governments have the primary responsibility for promoting a more equitable approach to health and human rights, a wide range of civil society groups and movements, and the media have an important role to play in ensuring people’s power and control in policy development and in the monitoring of its implementation.

This Charter calls on people of the world to:

Build and strengthen people’s organisations to create a basis for analysis and action.

Promote, support and engage in actions that encourage people’s involvement in decision-making in public services at all levels.

Demand that people’s organisations be represented in local, national and international fora that are relevant to health.

Support local initiatives towards participatory democracy through the establishment of people-centred solidarity networks across the world.

The People’s Health Assembly and the Charter

The idea of a People’s Health Assembly (PHA) has been discussed for more than a decade. In 1998 a number of organisations launched the PHA process and started to plan a large international Assembly meeting, held in Bangladesh at the end of 2000. A range of pre- and post-Assembly activities were initiated including regional workshops, the collection of people’s health-related stories and the drafting of a People’s Charter for Health.

The present Charter builds upon the views of citizens and people’s organisations from around the world, and was first approved and opened for endorsement at the Assembly meeting in Savar, Bangladesh, in December 2000.

The Charter is an expression of our common concerns, our vision of a better and healthier world, and of our calls for radical action. It is a tool for advocacy and a rallying point around which a global health movement can gather and other networks and coalitions can be formed.

Join Us – Endorse the Charter

We call upon all individuals and organisations to join this global movement and invite you to endorse and help implement the People’s Charter for Health.

PHA Secretariat,
e-mail: phasec@pha2000.org,
link to PHA site

Coordinating Committee:

Asian Community Health Action Network (ACHAN)

Consumers International

Dag Hammarskjöld Foundation (DHF)

Gonoshasthaya Kendra (GK)

Health Action International (HAI)

International People Health Council (IPHC)

Third World Network (TWN)

link to PHA site

Allyson M Pollock and David Price, The WTO & privatisation of health care systems

Allyson M Pollock, David Price

Rewriting the regulations: how the World Trade Organisation could accelerate privatisation in health-care systems

Lancet 2000; 356: 1995-2000

Health Policy and Health Services Research Unit, School of Public Policy, University College London, London WC1H 9EZ, UK

Correspondence to: Prof Allyson M Pollock
Allyson M Pollock, David Price

The World Trade Organisation (WTO) is drawing up regulatory proposals which could force governments to open up their public services to foreign investors and markets. As part of the General Agreement on Trade in Services (GATS) negotiations, the WTO working party on reform of domestic regulation is developing a regulatory reform agenda which could mark a new era of compulsion in international trade law. Article VI.4 of the GATS is being strengthened with the aim of requiring member states to show that they are employing least trade-restrictive policies. The legal tests under consideration would outlaw the use of non-market mechanisms such as cross-subsidisation, universal risk pooling, solidarity, and public accountability in the design, funding, and delivery of public services as being anti-competitive and restrictive to trade. The domestic policies of national governments will be subject to WTO rules, and if declared illegal, could lead to trade sanctions under the WTO disputes panel process. The USA and European Union, with the backing of their own multinational corporations, believe that these new powers will advantage their own economies. Health-care professionals and public-health activists must ensure that this secretive regulatory reform process is opened up for public debate.

Sue Kerrison and Alison MacFarlane (editors), Official Health Statistics: an Unofficial Guide

Sue Kerrison and Alison MacFarlane, editors

Official Health Statistics: an Unofficial Guide

ISBN: 034073132X

Arnold Publishers, 2000

CONTENTS:

Chapter 1 SETTING THE SCENE
The government statistical service and the collection of official health statistics
Susan Kerrison and Alison Macfarlane

Chapter 2 SURVEYING THE POPULATION
Health topics in censuses and surveys
Mary Shaw, Danny Dorling and Jenny Grundy

Chapter 3 MATTERS OF LIFE, DEATH AND ILLNESS
Births, congenital anomalies, deaths, communicable diseases and cancer
Alison Macfarlane, Azeem Majeed, Neil Vickers, Phil Atkinson, and John Watson

Chapter 4 LOOKING AT HEALTH INEQUALITIES
Social class, disabled people and ethnic origin
Alison Macfarlane, Mel Bartley, Susan Kerrison, and Jenny Head

Chapter 5 MONEY MATTERS
Measuring poverty, wealth and unemployment.
Paul Johnson, Sarah Tanner, and Ray Thomas

Chapter 6 HEALTH AT WORK AND HOME
Occupational ill health, housing and diet
Ben Armstrong, Rebeka Widdowfield, Yoav Ben shlomo, Eric Brunner, and Annette Boaz

Chapter 7 ENVIRONMENTAL MATTERS
Industrial pollution, air pollution and transport
Mary Taylor, Susan Kerrison, Sue Hare, Stephen Potter, Adrian Davis, and Ben Lane

Chapter 8 HEALTH CARE
Monitoring the NHS
Alison Macfarlane, Susan Kerrison, Declan Gaffney, and Sylvia Godden

Chapter 9 SOCIAL SERVICES STATISTICS
Statistics chasing the policy tail
Nick Miller and Robin Darton

Ana Costa, Edgar Hamman-Merchan y Debora Tajer (compiladores), Salud, equidad y genero

Ana Costa, Edgar Hamman-Merchan y Debora Tajer compiladores

“Salud, equidad y genero. Un desafio para las politicas publicas”

Editado por ABRASCO, ALAMES y la Editora de la Universidad de Brasilia,

Solicitar libro a ALAMES

El libro es el resultado de los trabajos presentados, durante el I Encuentro Latinoamericano “Salud, Equidad y Genero. Un Desafio para las Politicas Publicas” que se llevo a cabo en la ciudad de Rio de Janeiro, Brasil los dias 18 y 19 de septiembre de 1999

Organizacion: Red de Genero y Salud Colectiva de la Asociacion
Latinoamericana de Medicina Social -ALAMES y Grupo de Trabajo de Genero y Saludde la Asociacion Brasilera de Salud Colectiva ABRASCO

Articulos:
1. Globalizacion y Reforma del Estado.
Asa Cristina Laurell
Maestria en Medicina Social, Universidad Autonoma Metropolitana-X, Mexico. Secretaria de Salud, Mexico D.F.

2. La Impotencia de la Reforma
Roberto Passos Nogueira.IPEA/Nucleo de Estudios en Salud Publica, Universidad de Brasilia

3. Salud en las Reformas Contemporaneas
Celia Almeida. Red de Investigacion en Sistemas y Servicios de Salud del Cono Sur

4. Poros y grietas de los Modelos de Gestion en Salud
Maria de los Angeles Garduno Andrade. Maestria en Medicina Social, Universidad Autonoma Metropolitana-X, Mexico

5. Genero y equidad: desafios de los procesos de Reforma sectoriales en salud
Maria Urbaneja. Ministra de Salud, Venezuela. Coordinadora General
ALAMES 94/00

6. Generando la Reforma de la Reforma
Debora Tajer. Prof. Adjunta Estudios de Genero, Universidad de Buenos Aires.
Coordinadora Red de Genero ALAMES. Coordinadora General ALAMES 01/02

7. Participacion y reforma de la salud: nuevas expectativas, viejas formas
Jeannine Anderson. Universidad Catolica, Peru

8. Salud de la Mujer en la reforma sanitaria brasilera
Ana Maria Costa.
Coordinadora NESP-UNB y Estela Leao Aquino, Coordinadora MUSA, UFBA y Grupo de Trabajo Genero y Salud ABRASCO

9. Nociones Respecto a la Perspectiva de Genero de Directivos de Programas Nacionales del Ministerio de Salud del Peru
Pilar Campana Segovia, Universidad Cayetano Heredia, Peru

10. Genero y modelo de Gestion en Salud del Municipio: la Experiencia de Riode Janeiro
Cristina Boaretto. Secretaria de Salud de Rio de Janeiro

11. Violencia Intrafamiliar en la Reforma del Sector Salud de Centroamerica
Lily Caravantes. Organizacion Panamericana de la Salud- Guatemala y Lea, Guido Representante OPS-Haiti

12. Genero, Participacion, Empoderamiento y Control Social en Salud
Magally Huggins Castaneda. Universidad Central de Venezuela

13. Mujeres y Control Social en Salud ?Hacia una Potenciacion de Genero?
Maria Isabel Matamala Vivaldi Coordinadora Adjunta Red de Salud de las
Mujeres Latinoamericanas y del Caribe, Chile

14. Genero y Control Social en Salud: la Omision de los Gobiernos y los
Limites del Monitoreo. Jandira Feghali. Diputada Federal, Brasil

15. Derecho y Control Social
Humberto Jacques de Medeiros. Procuradoria de la Republica, Brasil

Vicente Navarro, Assessment of the World Health Report 2000

Assessment of the World Health Report 2000

Lancet 2000; 356: 1598-601

Public Policy Program, Johns Hopkins University, USA-Pompeu Fabra University, Spain (Prof V Navarro MD); School of Public Health, Johns Hopkins University, 624 N Broadway, Room 448, Baltimore, MD 21205, USA

Correspondence to:

Prof Vicente Navarro, School of Public Health, Johns Hopkins University, USA Vicente Navarro

On June 24, 2000, the WHO released a report that assessed the world’s health-care systems based on an overall index of performance.1 The report had an immediate and enormous impact and was discussed on the front page of almost every major newspaper in the western world and on the broadcast news. The WHO, the health agency of the United Nations (UN), had assessed health-care systems around the world and everyone wanted to know where his or her country was placed in the health-care system league.

In health-policy circles, the report caused some big surprises. At the top of the WHO’s health-care league were countries such as Spain and Italy, whose health-care systems were rarely considered models of efficiency or effectiveness before. In Spain, for example, release of the WHO report, which ranked the Spanish system as the third best in Europe, after Italy and France, coincided with unprecedented demonstrations against the Spanish health-care authorities. Demonstrators were protesting against the long waiting lists for critical life-and-death interventions (which had been responsible for a large number of deaths) and the short consultation times in primary-care centres (an average of 3 mins per consultation). This state of affairs in the Spanish system had forced prominent professional associations, including the Spanish Association of Primary Care Physicians, to denounce the current situation as “intolerable” (these events were widely reported in the Spanish press in June and July; see, for example, the series in El Pais in June 2000). The growing popular protest had put Spain’s Conservative government on the defensive, until the WHO brought out its report listing the Spanish system as the third best in Europe and the seventh best in the world. Spain’s Conservative Minister of Health showed the WHO report to the protesters as proof of the unjustified nature of their complaints and demands.

The protesters, however, were not impressed by the WHO’s ranking of Spain’s health-care system. Something seemed profoundly wrong in the report’s claiming that the performance of the Spanish system was the seventh best in the world. The report’s conclusions certainly did not coincide with the perceptions of most Spanish people. In one of the most rigorous surveys of views of the Spanish population regarding health care, Spaniards expressed more discontent with their system than did the population of any other major country in the European Union, except Italy, whose health care was also listed among the “best” in the WHO report. An impressive 28% of the Spanish population (and an even more impressive 40% of the Italian population) indicated “there was so much wrong with their HCS (health-care system) that they needed to completely rebuild it”, and an additional 49% of the Spanish population (and 46% of the Italian population) stated that “there were some good things in their HCS but fundamental changes were needed to make it better.”2 There was indeed a disagreement about the definition of performance by the WHO and by the Spanish and Italian populations. Who is right? In order to answer this question, we must first understand that the WHO is not a scientific but rather a political institution whose positions and reports must be assessed both scientifically and politically.

The objective of the WHO ranking

Why do we need to rank countries according to the performance of their health services? Presumably, an important objective is to see what we can learn from “the best”, using them as points of reference on the road to better health. A very important element in the WHO ranking, however, is the credibility of the indicators of performance that it uses. It is therefore important to know how the ranking was developed, the assumptions behind the preparation of the indicators used in the ranking, and the consequences for health policy of choosing one indicator versus another.
Let us start with the nature of the indicators. The WHO report develops three types of indicators. The first is related to the effectiveness of the health-care system (mainly medical care plus traditional public-health services) in reducing mortality and morbidity. The second is related to the responsiveness of the system to the user, understanding responsiveness as the ability to protect the user’s dignity; to provide confidentiality and autonomy; to provide care promptly with high-quality amenities; to provide access to social support; and to ensure a choice of provider. And the third type of indicator is related to the fairness of the system, measured by the degree of progressiveness in the funding of health care.

All three types of indicators are weighted and added to create a single indicator, the indicator of performance. It is unclear why the WHO felt the need to come up with one synthetic indicator of performance. There is not, after all, a single UN indicator for ranking countries by economic performance. Rather, the annual UN economic reports use specific indicators to measure different components of economic efficiency such as unemployment, economic growth per capita, rate of productivity growth, and so on. But no single indicator summarises the many dimensions of the equally complex issue of economic performance. So why did the WHO decide to make a single indicator for performance of health-care systems? The WHO report is silent on this point.

Effectiveness of health-care systems

In the WHO’s conceptualisation of medical-care effectiveness, the report uncritically reproduces a major assumption in medical-care cultures that medicine is very effective in reducing mortality and morbidity. I find it astonishing that a prominent public-health agency could state:

“The differing degrees of efficiency with which health systems organize and finance themselves, and react to the needs of their populations explain much of the widening gap in death rates between the rich and poor, in countries and between countries, around the world”.

No evidence is given for such a statement. Actually, published literature shows that much of the widening gap in mortality rates within and among countries is primarily related to the growing differentials in wealth and income.3

“Health systems have played a part in the dramatic rise in life expectancy that occurred during the XX century”.

Here again, no scientific data are given to support such a statement. Actually, the evidence shows that the most dramatic declines in mortality and increases in life expectancy occurred during the 20th century before medical care proved effective. Indeed, most dramatic changes in mortality during the century were the result of social and economic interventions.4.5

“If Sweden enjoys better health than Uganda–life expectancy is almost exactly twice as long–it is in large part because it spends exactly 35 times as much per capita in its health systems”.

Again, no evidence is given for this statement. All the scientific data show there is no link between the level of expenditures in health-care systems and level of mortality. There is evidence, however, for a link between political interventions, wealth and income distribution, and mortality indicators.6

This enormous faith in the effectiveness of medical care reaches extreme proportions when the WHO report indicates that with “an investment in health care of $12 per person, one third of the disease burden in the world in 1990 would have been averted”. Thus, the report gives the impression that the major problems of mortality and morbidity are a consequence of the limited resources of health-care systems. Give more money to a health system and more lives will be saved. The report even quantifies how many lives could be saved per dollar invested. Very neat, but profoundly wrong. Nowhere does the WHO report present any scientific evidence to support these wild assertions. Again, most available data show that other factors are far more important in explaining a country’s level of health and mortality than are its medical services. Any student of public health knows that medicine is not as effective in reducing mortality and morbidity as the medical establishment believes. Indeed, there is extensive literature on the social, cultural, economic, and political causes of health and disease. That medical care is less effective in reducing mortality than the WHO report assumes does not mean, of course, that medicine is not useful in taking care of patients’ medical conditions and improving their quality of life. But it is wrong to explain a country’s level of mortality by its medical services. Not even public-health interventions (such as immunising against childhood diseases), which have been far more effective in reducing mortality than have medical-care interventions, can be considered the main reasons for the mortality decline in the 20th century. Social, economic, and political interventions are the primary reasons for this decline.

This mistaken assumption–overestimating the effectiveness of medical and health care–explains why some countries, such as the Mediterranean countries, Spain, Italy, Portugal, and Greece, which traditionally have good health indicators with long life expectancies, earn high marks in the WHO’s classification of effectiveness. The report erroneously attributes the low mortality in these countries to the effectiveness of their medical care. Actually, these various Mediterranean countries have different types of health services, but all share the characteristic that public expenditures in the health-care system as a percentage of gross national product are among the lowest in the EU. Table 2 (basic indicators for all member states) of the WHO report shows these are among the countries with the lowest probability of dying (per 1000) for children under 5 years and for adults between 15 and 59 years, and with the longest life expectancy in the world. None of them have large health-system expenditures. Their types of funding and organisation are extremely varied–with the common denominator, however, of the populations’ high level of dissatisfaction with their health systems. Actually, the WHO report lists these health systems as among the least responsive (to users) of all European systems. In the ranking for responsiveness, Spain is listed 34th, Greece 36th, Portugal 38th, and Italy 23rd, all of them among the least responsive in the EU. It would seem then, according to the authors of the WHO report, that the effectiveness of health-care systems in reducing mortality outweighs their limited responsiveness. They are thus considered user-unfriendly but very effective nevertheless. It is highly questionable, however, whether the good mortality indicators of these countries are the results of health-care system interventions.

Who defines the indicators of responsiveness?

The second component of performance is related to what the report called “responsiveness” of the health-care system to users. The report includes here two major groups of considerations. The first deals with what the report calls “respect for persons”, which includes the dignity afforded to the patient, the confidentiality of patients’ information, and patients’ autonomy. The second group is referred to as “client-oriented attributes”, such as prompt attention to the patient, the quality of the amenities, access to social support networks, and choice of provider. It would seem that these characteristics should give a fairly good idea of how responsive a health-care system is to its users.

Conceptually, then, indicators of responsiveness seem to be reasonable. The problem arises when we see that the people who defined the values of these indicators and the weights given to each (derived from questionnaires) are what the WHO report calls “key informants”, without specifying who those key informants are. These unknown key informants are most likely experts on health care in the various countries. And the survey of these informants is therefore likely to be a survey of the “conventional wisdom” among experts who define the degree of responsiveness of health-care systems to users. The report does not explain who these key informants are, nor does it explain the criteria for their selection. It is likely, however, that the choice of these informants and experts was highly biased towards what are called health-care-establishment figures. Indeed, the selection of references in the report’s bibliography is quite biased and prejudiced against critical positions, issues, or authors. One can find consistent references to conservative and neoliberal authors (such as Alain Enthoven of Stanford University, USA) and mainstream medical journals, but never does the report make reference to critical authors or scientific journals that question established wisdom.

Not surprisingly, therefore, the survey of responsiveness reveals that the countries with more responsive health-care systems are those whose health policies better fit what has become the new conventional wisdom. In this thinking, health-care services that combine public funding with public provision of health care (which has characterised national health services) are out. They are constantly referred to as examples of “heavy handed state intervention . . . the type of intervention discredited everywhere”, “highly impersonal and inhuman (as in the pre-1990 Soviet Union)”, and “monolithic”. The abusive nature of the disqualification of these types of health services is all too clear when the collapse of the Soviet Union is used as an example of the deficiencies of national health services. The fashionable thing now, in current conventional thinking, is an insurance system with a public-private mix that allows for competition between managed care plans, giving patients–referred to as clients–increased choice of providers and permitting more flexibility. The WHO report presents the Thatcher reforms in the British national health service as worth extrapolating to other systems. We should not be surprised that these key informants and experts selected the USA as having the system that is most responsive to users, and Colombia, a Latin American country whose national health service has been replaced by an insurance-based managed care competition model, as having the most responsive system in Latin America.

This profoundly ideological position of the WHO report also comes across in its analysis of what the WHO considers the “failure” of the Alma-Ata approach. The Alma-Ata Declaration was a famous WHO report, written in 1978, which emphasised the importance of primary-care services, combining medical with social interventions at the primary level of care. The new WHO report assumes that implementation of the Alma-Ata report failed because, in designing such primary-care models, too much attention was given to the health needs of the population and not enough to the demand for services; the Alma-Ata report was too oblivious to the importance of the private sector and the market. According to the WHO’s June, 2000, report, countries should give far more importance to reforms that aim at “making money follow the patient, shifting away from simply giving providers budgets, which in turn are often determined by supposed needs”, as many countries are now doing. The report also indicates that there is a link (nowhere documented) between expansion of private delivery of services and responsiveness of the health-care system. This shift from planning according to need toward demand in the market is a radical change in WHO policy, a change I consider antagonistic to the basic principles of public health.

Not surprisingly, besides choosing the USA as the country with the most responsive system, the WHO report considers the greatest challenge facing government-based health systems is to respond to the need for regulating the private sector, a function, say the authors, that most countries are not prepared for. The model they advocate is that put forward by Enthoven (an author cited approvingly in the report), which inspired the Thatcher reforms in the British national health service.

Consequently, given the political and propagandistic character of the report, nowhere do we find quoted, cited, or argued the huge amount of scientific evidence that questions each of the assumptions made in the report and challenges the superiority of insurance-based health-care systems. (There is an extensive literature critical of insurance-based managed care, mostly published in the International Journal of Health Services in the 1990s). To make the USA the top-ranked country in responsiveness to health-care users not only ignores the large body of scientific evidence that shows just how unresponsive the US health service actually is, but also sets aside any observation of the political context of health policy in the USA. The Democratic Party is now trying to identify managed care and managed competition, and their unresponsiveness to users, with the Republican Party as a way of gaining some political advantage in the coming Presidential and Congressional elections, knowing how unpopular managed care and managed competition are with most citizens of the USA.

Unfortunately, however, the WHO is doing what its American branch, the Pan-American Health Organisation (PAHO), has been doing for years–functioning as a transmission bell for Latin America of the conventional wisdom in US financial and political circles. In recent years we have been witnessing how the PAHO and now the WHO, with the assistance of the World Bank and private foundations, are presenting insurance-based managed care as part of the solution to the burgeoning health-care problems in Latin America.7 The privately managed health-insurance schemes are seen as playing a positive role in complementing and competing with the government health-care systems. In a recent speech to corporate and academic leaders in the USA, the Director General of the PAHO referred to the successful experience of several private health insurance schemes in Latin America, taking Instituciones de Salud Previsional (ISAPRES), the major private insurance scheme in Chile, as an example: “The example of ISAPRES in Chile shows the possible success of the privately managed health and social insurance schemes

Celia Sarduy Sánchez, Ada Caridad Alfonso Rodriguez, Género: Salud y Cotidianidad

Sarduy Sánchez, Celia / Alfonso Rodriguez, Ada Caridad

Género: Salud y Cotidianidad. Temas de actualidad en el contexto cubano

Editorial Cientifico-Técnica, La Habana, 2000

ISBN 959-05-0258-x
Instituto Cubano del Libro
Editorial Cientifico-Tecnica
Calle 14 no 4104, entre 41 y 43, Playa,
Ciudad de La Habana, Cuba

Índice
Prólogo Mayda Álvarez Suárez

Presentación Adá C. Alfonso Rodriguez

Introduction Celia Sarduy Sánchez

Ser mujer en Cuba. Riegos y conquistas Patricia Arés Muzio

Salud mental de las mujeres y vida cotidiana Adá C. Alfonso Rodriguez

Genero y vinculo amoroso Lourdes Fernández Rius

Salud sexula y reproductiva. Reflexiones con los jovenes. Natividad Guerrero Borrego

Salud y trabajo domestico Adá C. Alfonso Rodriguez y Celia Sarduy Sánchez

Alimentacion, nutricion y cotidianidad.¿Un problema de mujeres? Francisca Valdespino Breto

Educar la sexualidad en la familia. ¿Una responsabilidad de mujeres? Inalvis Rodrigues Reyes

Mujer,genero y SIDARosaido Ochoa Soto y Murna Villalón Oramas

Niñas y niños opinan sobre el SIDAElcida Álvarez Carril

Genero y prostitución: algunas refelxiones a las puertas del tercer milenioAna Isabel Peñate Leiva

Salud y violencia de genero Juana Iliana Artiles de León

Mujer y poder en CubaMayda Álvarez Suárez

Indicadores de salud. Una alternativa para el analisis de la salud desde la perspectiva de generoIleana Castañeda Abascal y Héctor D. Bayarre Vea

Enfoque de genero: una necesidad de la investigacion gerontologica en el contexto cubano Héctor D. Bayarre Vea

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