ICPD + 15: Debating Health Care When It’s No Longer 'Business as Usual'
The raging debate on health care in the United States appears to be all about the cost of services, the burden of shouldering the expense and deciding whether or not the state has a role in addressing the inevitable conflict over the balance of benefits and burdens. But the drama unfolding in town halls across the United States - with the rest of the global village watching -- demonstrates that this time, the stakes go way beyond the usual bureaucratic or even technocratic challenges in health service delivery.
Conceiving health as a right makes a profound difference not only in how people claim individual entitlements to health and standards of care, but also highlights the role of public institutions both in service provision and as purveyors of common interests. When the right to health belongs to everyone regardless of race, class, sex and religion, confronting the issue of social inequality is inevitable. Fifteen years ago, the International Conference on Population and Development (ICPD) brought a special focus on sexual and reproductive health which unlike other fields of health is the most implicated by socio-economic and cultural factors. Religious traditions are invoked against women's empowerment and decision making over their reproductive well being. The same conservatism bars the education of young people on matters vital to their sexual and reproductive health. And while there are signs of progress as in the recent cases of Mexico (when the city passed an ordinance decriminalizing early term termination of pregnancy) and India (where the courts struck down the penal law against sodomy), archaic laws all over the world continue to perpetuate discrimination primarily against women and homosexuals. Indeed gender is a significant marker of social and economic vulnerability and its impact is visible from inequalities of access to health care to the gender differences that dictate people's social positions as users and producers of health care.
Fifteen years later, many of the original opponents of the ICPD's framework of health as human rights can be expected to voice the same antagonism against the ICPD, specifically its challenges to gender-based inequality, traditional gender roles coupled with its positive frame on sexuality. But while the opposition seems the same, the context has changed quite radically. For one, while the US debacle over its health systems is easily dismissed as a localized phenomenon, it's also important to draw lessons from the experience given that decades ago (long before the ICPD), many developing nations embraced health sector "reforms" founded on the same faith in market principles to cure the various ills of their health systems and they show no signs of rethinking such strategies.
In fact even before the ICPD, pundits were already sounding alarm bells
about the free market principles behind many health sector reform initiatives. In
Hsiao called "marketization as the illusory magic pill" that developing
nations were depending on to alleviate their underfunded and inefficient public
sector dominated health systems. Yet as several countries' experiences later
proved, the push
towards marketization did not occur outside a geo-political vacuum.
From Mexico to Nigeria, the Caribbean and the Philippines, HSR traces its origins from Structural Adjustment Programs which prescribed cut-backs on government spending including social services. Budget cuts affected marginalized sectors but poor women bore the brunt as providers of health care. Majority of community-based health workers in the global south are women volunteers or minimally paid workers. In the meantime, key health professions such as nursing and care giving grew even more focused on job markets abroad. A case in point is the Philippines where remittances from overseas workers have been the single-most determining factor of continuing economic survival. Thus it may be argued (and it has been argued) that catering to the first world market in health serves the economy. As in the Philippines, qualified health professionals from Ghana, Malawi, Zambia and South Africa often seek employment abroad. In 2002 the World Health Organization (WHO) warned that the trend of migration of nurses from third world countries would seriously jeopardize the ability of many health systems to function. Indeed shortages of skilled professionals such as nurses with midwifery skills, are now linked to gaps in the provision of maternal, newborn and child health.
ICPD+15 is an opportunity to reflect on public health systems as core social institutions in the face of market failures and inadequacies, including corporate ineptitude in safeguarding the finances ordinary people depend upon for their health and well being. As Lynn Freedman points out, health systems are part of the very fabric of social and civic life - because they function at the interface between people and the structures of power that shape their broader society. Health as a right is premised on social justice.