63. Food for a Poor Thought on Health and Poverty - Health a Precious Asset, But Not ‘A New and Potentially Powerful Exit Route from Poverty’

HEALTH A PRECIOUS ASSET (^*), BUT NOT ‘A NEW AND POTENTIALLY POWERFUL EXIT ROUTE FROM POVERTY’ (^**)

^*: Health a Precious Asset - Accelerating Follow-up to the World Summit for Social Development - Proposals by the World Health Organization, WHO/HSD/HID/00.1, 2000.

^**: Dr G.H. Brundtland, referring to WHO’s "corporate" strategy during WHO’s executive board meeting, 105^th session, Jan 24, 2000.

WHO’s proposal for a Copenhagen plus Five follow-up is indeed an uneven document (*). It has a powerful and quite progressive analysis of “the health revolution that has left out a billion people” and “the health services in crisis”. But it falls short in suggesting remedies that could address what it criticizes. Moreover, some of the proposed areas of action clearly contradict the analysis.

Its merits notwithstanding, I will here only focus on what I think are the negative and contradictory aspects of the integral health components of poverty reduction WHO proposes for the follow-up of Copenhagen+5.

WHO’s proposals for Strengthening Global Policy for Social Development are left very general and vague: They call for turning globalization to the full advantage of poor and marginalized populations, but they do not tell us how. They call for designing responses to the negative effects of globalization on health equity, but they do not tell us how. They pledge to help making trade work to improve health, but they do not tell us how. They call for developing of health protection norms to guide the business sector when they have criticized the capacity of this sector in the analysis earlier on. They further call for building a global knowledge base on social development with regard to health, but they do not tell us what good this will do. (p.16)

When it comes to proposing Actions to Integrate Health Dimensions into Social and Economic Policy, the introduction of health impact assessment analysis tools is portrayed as being new (when they are not) and does not zero-in on the need for a differential impact assessment that singles out the inequities suffered by the poor and marginalized. WHO then goes on to offer guidance to countries on the specific mix of investments they need across sectors to ensure poverty reduction when the document has said earlier (on p.14) a) that market interventions in health care are anti-poor (as well as likely to deepen current inequities), and b) that the private sector generally does not provide quality health care at reasonable cost (public intervention is necessary to achieve universal access, they correctly add). Promoting social insurance (formal and informal) is rightly highlighted as a necessary measure, but no elaboration follows this statement. Finally here, WHO proposes to provide evidence for elaborating technical options as the basis for more informed macroeconomic decision-making; one is, of course, left wondering how much technical options -in the absence of political options- will achieve... (pp.17, 18)

Then, under Developing Health Systems which Target Health Problems Affecting Poor and Vulnerable Populations, the document again calls for marshaling the efforts of private providers to contribute to improving the health of the poor; the silver bullet on how to exactly do this is assumed to be self-explanatory. We are then promised that the World Health Report 2000 (which has created an uproar) will address in depth what policy makers and program managers can do to create more equitable health systems. Now, did it really?

A great deal of emphasis is laid on championing substantial reductions in the misery caused by major diseases affecting the poor calling these (mostly vertical) programs “pro-poor”; but WHO fails to say that this is strictly palliative and that none of this attacks the roots of poverty itself thus preventing that more poor are affected equally later on. The major factor leading to poverty simply is not illness per-se. Moreover, targeting the poor mostly victimizes them as if they were responsible of their fate, but that is not said. In our daily work, we are told, the tools we use to control health problems are failing due to “market failures”, not even considering that they may be the wrong tools being applied on the wrong end of the problems. (pp.19, 20)

Most of my problems with WHO’s position on Copenhagen+5 come from the last page of the document. It calls for Promoting a Responsible Health “Sewardship”-as if we had a shortage of jargon around. As it turns out, this is to mean ensuring responsible management (or harmonizing functions and overseeing all components of the health system, as is said...), This, as if better management alone would be able to redress the situation in which the health revolution left out a billion people... Then, towards the end, the contradictions simply pile up:

- Ministries of health need to make efforts to engage the resources of the private sector (...the provisions of the private sector are especially important for the poor...!; financial incentives and contracts are to be given to the private sector, at the same time assuring that private insurance and the pharmaceutical houses contribute to the overall goals of the health system).

- Ministries are to shift from ‘rowing to steering’, i.e. from directly providing to overseeing multiple actors and holding them accountable through stronger monitoring (but no hint is given on how and if such a monitoring alone will change thing for the poor for the better). (p.21)

If this all does not sound like WB language then I do not know what will. (Actually, on p.15, the document calls for WHO to strike partnerships: it singles out close collaboration with the WB and the IMF leaving other agencies unmentioned).

To me, it seems that this WHO proposal was written by different teams and then was hastily put together without checking for consistency. I stand to be proven wrong, but until then, somebody better fix this conundrum.

Claudio Schuftan, Hanoi
aviva@netnam.vn