Perspectives on global health and the way forward
Published online: September 14, 2018
Global Health Watch 5 – An alternative world health report, London: Zed Books; 2017, 448 pp. $29.99(Paperback), ISBN 9781786992239.
The Global Health Watch reports originated at the World Health Assembly in May 2003 as an alternative to the “inadequate” WHO reports, which were found to be faltering in their response to the growing neo-liberal discourse and its consequences. The Watch was envisaged to enable a more people-centric approach that would broaden and strengthen the global community of health advocates to act on global ill health and inequalities as well as their underlying political and economic determinants. In September 2015, the UN General Assembly adopted a resolution on 17 Sustainable Development Goals (SDG) and recognised, at least on paper, that health and well-being are part of a global and integrated approach based on socially inclusive and sustainable economic growth strategies that preserve the planet.
The book describes in detail how the SDGs appear to be about “constraining the predatory nature of capitalism”, but, in reality, perpetuate the current neoliberal model of ever increasing extraction, production and consumption. These, in turn, are seen to be prime drivers of poverty, environmental degradation and sustained inequality. The book states that “the poorest 60% of humanity has received only 5% of the income generated by global GDP growth between 1999 and 2008”. Structural adjustment programmes, the greatest single cause of poverty since colonialism and imposed on developing countries by the World Bank, the International Monetary Fund and the European Union (in Greece) are never mentioned in the SDG; neither is there a demand for strong regulation and accountability of the financial markets The authors feel that for these global targets to become real changes, and not just empty words, it is necessary to involve social organisations, civil society, academics, community representatives, and citizen assemblies.
They argue that global governance is being increasingly reoriented to allow direct participation of private actors alongside states, weakening democratic representation. Established global structures like the United Nations and World Health Organisation (WHO) are under a barrage of assaults, with their agency and independence being rapidly eroded. The WHO is financed through a mix of assessed and voluntary contributions. Shortfalls in public funding have obliged the WHO to turn to private, corporate philanthropic organisations – aptly described as “philanthro-capitalism”. The consequences have been a focus on vertical programmes, a disproportionate budget allocation for vertical programmes, a negative effect on research systems, public private partnerships, lack of accountability, weakened leadership, alienation of communities and opening up of markets to multinationals..
Universal Health Coverage
The term Universal Health Coverage (UHC), widely used in global health parlance, is open to multiple and often contradictory interpretations. A primary healthcare approach foregrounds community involvement in decision making, planning, accountability and prevention. In stark contrast is the argument for purchasing healthcare as a commodity, often at costs that governments and communities can ill afford, while dismantling even existing public services. The burgeoning “Medical Industrial complex” has no qualms about conflict of interest, pollution of rational and independent scientific research, lobbying, extortion, arm-twisting, bullying, coercion and bypassing regulatory mechanisms.
Determinants of health
Global Health Watch 5 (GHW 5) discusses how UHC depends on multiple determinants of health which have to be addressed for health to become a reality.
The report presents shocking statistics around international migration and one cannot ignore the consequent high levels of global inequity, ecological mayhem, exclusion, misconceptions and multiple levels of vulnerability. In 2015 the estimated number of international migrants was 244 million, up from 173 million in 2000 – “Migration is fuelled by a large number of factors interacting in multiple and complex ways. Over past four decades, globalisation and neoliberal polices have played a particularly significant role as drivers of both internal and international migration”.
Women’s choice and autonomy in matters of sexuality and reproduction have to be factored into the discussion on UHC, and conditioned by social (class, caste, gender, race, religion, ethnicity, sexuality), economic and political structures.
Since the financial crisis and recession of 2008, global unemployment is at its highest, with much of the burden borne by low and middle income countries. It is of some concern that the broad umbrella of UHC hides the rapid informalisation of employment in public health services, which, in turn leads to low motivation, low retention of workforce, migration, employment insecurity and undignified work conditions.
The authors describe how community-led total sanitation is now being adopted in the rural areas of many Asian and African countries. The Swachh Bharat Abhiyan or Clean India campaign aims to construct millions of toilets but these stand-alone toilet construction programmes do not take into consideration the dimension of water availability, community choice, affordability, caste, gender and other issues. The coercive and mandatory nature of this programme has led to a number of infringements of peoples’ legal entitlements, privacy, financial security and human rights.
Securitisation of health was visible in the aftermath of the Ebola epidemic in West Africa and is symptomatic of how health issues, particularly those related to infectious diseases, have been presented as threats from developing countries to the developed ones. Rather than creating compassion and a shared global healthcare concern, this process creates fear, misallocates resources and undermines structural changes.
According to the authors the role of management consulting firms, which can be linked to all the significant global health institutions, has remained “hidden from the public eye”.
The new public management strategy brings in vocabulary such as private sector efficiency, cost effectiveness, project management skills, public-private partnerships, value for money, results-based financing, high impact interventions etc, and result in those with the greatest need losing out. Civil society also is compelled to engage with the same “obscure jargon” as opposed to the rights-based or practical approach, with confidentiality becoming an excuse against transparency.
Rampant industrial growth and activities propelling the global economy have brought about economic degradation with depletion and contamination of land, water, air, all of which have health consequences. With eight billionaires in 2016 possessing wealth equivalent to the world’s poorest 3.6 billion, and temperatures of each of the last three years being the warmest on record, the per capita ecological footprints of wealthy nations are achieved by consuming other people’s share of the planet’s resources. The only solution, namely a dramatic reduction in the level of material consumption by the better off, “contravenes the very logic that drives the capitalist system”. Unless this is addressed, the planet is only hurtling towards irreversible destruction of its natural resources.
The GHW 5 has undertaken the daunting task of documenting several dimensions of healthcare and has been able to give the reader a broad overview of the global scenario
The book presents several examples of community processes that challenge the large global multinational agenda. Ecuador, building on its indigenous past, has incorporated the concept of summakkawsay or buenvivir (good living) as a community centred, ecologically balanced and culturally sensitive process. Although Latin America is seen as an example of a departure from the neoliberal discourse leading to impressive expansion of public services to provide universal access, there is a strong counter force that aims to destabilise the public services and bring in a market logic. The chapter on South Africa follows the development of civil society activism and reflects the changed nature of donor funding under neo-liberalisation characterised by directing of funding through private and non-governmental recipients in a climate of cuts in public spending.
GHW 5 is brave in its criticism and takes on the large corporations on behalf of people’s rights to health and its social determinants. It is important that bodies such as the People’s Health Movement, which have contributed to the GHW that set out to criticise top down, expert heavy approaches, are constantly introspective to makes sure that they don’t, over time, tread the same path. Is there diversity and representation in the groups that bring out this report? Has the PHM “leadership” only become the domain of a few who have permanent leadership positions? What efforts are being made to bring in more voices into this movement? Is there a second, third and fourth line of leadership being actively facilitated?
Although the writers say that the book was written pro-bono, it is also important to mention other sources of funding support to ensure transparency and avoid conflict of interest. While the authors talk about “NGOisation” of civil society, one also has to establish where one locates oneself in this spectrum.
Since the book repeatedly emphasises the role of community in all aspects of decision making, policy analysis and demand generation, what role is PHM playing towards making the information in this book widely available and minimising a crucial gap between theory/rhetoric and practice? Are there efforts to translate and disseminate into local languages and in a much less academic form? Some of these questions would need to be answered to prevent GHW 5 from being not just another report but a crucial part of an evidence-based process towards making healthcare more equitable, comprehensive, accessible and available.