It is nice to be part of discussions about the destiny of humanity, so it was with great interest that I read the draft report “Health in the post-2015 development agenda’. The task all of us face is one of extraordinary importance and responsibility when one of the possible destinies of mankind is extinction. Nobody can deny that our understanding of development (and the actions based upon it) have led to incredible achievements over the last few centuries. However, it is also becoming increasingly clear for more and more people that our economic system jeopardizes the sustainability of our planet. Interestingly, the draft report of the Global Thematic Consultation on Health does not discuss –or eventually propose– the need to reformulate the ideological principles that have caused the current (dire) state of the world. The draft report hints at them, at various places in the text, and obviously supports sustainable development as the new paradigm for the post-2015 world. Yet, real criticism of the ideological underpinnings of our economic system remains limited and mostly under the radar; also, the text is not very explicit on how the world should move towards a more sustainable economic system. This is a pity. Lack of political will to challenge the ideological foundations of our world economy limited the capacity of the health-related MDGs to achieve effective transformation and structural change. In the post-2015 world, this urgently needs to change, if mankind is to have a future. Capitalism and especially its most harmful exponent, neoliberalism, need to be thoroughly questioned. Clear pathways towards sustainable development should be offered, and editors/compilers of the report should not refrain from ideology. Although our world is more complex and interdependent than ever, ideology still matters. In fact, maybe it has never mattered more than now. I know the draft was just meant to be a preliminary technical report, but I feel it’s important to frame the enormous challenge we’re facing in this way, especially with a view on the final report which will be presented to the High-Level Panel in a month. That report should not mince words.
True, achieving Universal Health Coverage (UHC) and maximizing healthy life expectancy are comprehensive goals that can impact hundreds of millions of lives and that certainly integrate the health-related goals with others related to economic development – starting from the premise that health is a cause and consequence of well-being. Nonetheless, if we focus on UHC for example, it is important to keep the people in mind who should greatly benefit from the current UHC momentum. It should not be taken for granted that common citizens, including the most vulnerable ones, will automatically benefit. In Colombia, for example, a structural reform – 20 years ago– of the national health system aimed to achieve UHC, at least nominally. Yet, it has disproportionately favored private health insurance companies and negatively impacted the accountability of the health system. Brazil, on the other hand, has demonstrated that a Unified Health System – centrally administered by the State – is an effective way to guarantee the right to health. This, however, required a clear and sustained political commitment. Community participation, empowerment and effective mechanisms to influence policies were also important to keep up the pressure on politicians. In both cases, respectively a middle income country and a BRICs member, the proclaimed goal was UHC, but the outcome was very different. Political will to ensure the right to health through UHC is thus indispensable. The report could perhaps suggest ways to monitor and boost this vital political commitment & leadership and offer some ‘checks and balances’ to make sure politicians embarking on health care reform remain focused on the public good rather than on certain vested interests.
The draft report is very committed to the idea of equity. That is a big improvement over the MDG agenda. It is however disturbing that the strategies to promote equity (e.g. empowering of communities, social policies to mitigate the impact of markets) are most probably insufficient. It is well-known – and by now almost an axiom – that the current model of economic growth and development inherently produces (and worsens) inequity. Hence, if there are no (explicit and global) political commitments in the draft to promote structural change of the development model, I’m afraid we cannot expect a real impact on equity. Let’s not be naïve.
According to the draft, modifying social determinants is a key strategy to increase healthy life expectancy. The Social Medicine Movement from Latin America has insisted that only structural change – which includes modifying the economic and power relationships – can really impact the social determinants and the health situation of communities. It is thus very important how social determinants are defined – they should definitely include the political variables & power dynamics. As a Latin-American citizen, I’ve seen enough evidence over the last decades of the importance of politics, both for the better and for the worse.
The ongoing globalization is steered by many forces, both deliberate and implicit ones. Although the geopolitical environment is now finally changing, till recently it has been driven a lot by asymmetrical relationships between the North and the South. In many countries of the world, I’m sorry to say this is still the case. In the Latin-American region, for example, the main dilemma countries face now is between deepening neoliberal reforms to integrate their economies in the world (Colombia, Mexico, Chile are obvious examples) or going for a drastically different model, boosting the role of the state in providing goods and services (Venezuela, Ecuador, Uruguay). In this trade-off between more neoliberalism and a structural alternative with a bigger role for the state, equity is a key concern. From my point of view, the first group has not yet given a convincing answer to the question how they’re going to ensure equity while deepening neoliberal reforms. Needless to say, most international organisations (IMF, WB, …) support the former group and there’s relentless pressure on the second group to give in too. Only some big countries like Brazil can afford to follow their own agenda, at least to some extent.
If we aim to effectively achieve UHC and increase healthy life expectancy across the world we should thus aim to remedy this fundamental imbalance between North and South, update global governance mechanisms and make them more equitable. In the short term, we should compensate the Northern dominance by implementing financing mechanisms that go beyond charity. As many states in the North suffer from their own crisis now, it’s obvious the financial sector and multinationals will have to cough up the bulk of the money. A recent OECD report and last week’s G20 summit of Ministers of Finance are encouraging signs in this respect; at last, the international community seems to realize that international taxing has been very unfair in recent decades.
Zooming in a bit more on the Latin-American situation, I hope the final report will offer some suggestions to deal with continent-specific health problems, or at least allow for enough flexibility to let regional and national policy makers focus on very specific problems in their own environment. In Latin America, urban violence and narcotics are key issues. It’s not clear to me how the current draft proposal intends to tackle them.
We may be facing a unique opportunity to build a better world. In fact, it might be our last chance. If we want to accomplish the ambitious goals as proposed in the draft, we need besides lofty goals and technocratic targets also a strong political commitment and ideological stamina.