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The Global Health Debate

By Adam Parsons. Edited by John FeIIer, September 18, 2009

With controversy still raging over national health reform in the United States, the
media is paying little attention to an international debate on global health policy that is
of major importance to the world's poorest people. Both debates revolve around a
similar theme, which President Barack Obama neatly summarized in his recent
landmark address to Congress as "the appropriate size and role of government" in the
provision of health services.
In the late 1970s, long beIore the U.S. House oI Representatives introduced the bill
"Medicare Ior All" (H.R. 676), the World Health Organization (WHO) and its member states
(including the United States) embraced the greater goal oI "health Ior all." The approach to
achieve this universal target, termed Primary Health Care (PHC), encompassed a vision oI a
new international health strategy that is today gaining renewed attention Irom policymakers,
health proIessionals, civil society, and the United Nations.
While the healthcare discussion in the United States is Iramed by the objective oI universal
coverage, the debate on PHC has long been guided by the same aspiration Ior developing
countries. Global health care reIorm is again on the agenda oI the international community,
though it Iaces some oI the same challenges that Obama's initiatives have encountered in the
United States.
Origins of PHC
According to the PHC vision, addressing the socioeconomic determinants oI health, not just
the medical consequences oI sickness and disease, is Iundamental to reducing the global
inequities in healthcare provision. In 1978, when ministers Irom 134 countries gathered in
Alma-Ata, Kazakhstan, and signed a declaration calling on nations to reduce the gap between
the health status oI the developing and developed countries, they considered the slogan
"Health Ior All by the Year 2000" as a laudable and achievable goal. Not only did it involve
guaranteeing access to essential health care at a community level Ior all people oI the world,
but PHC services were to work closely with health-related sectors responsible Ior other
essential needs including education, saIe water, sanitation, and Iood security.
The sense oI optimism amongst health policymakers was unIortunately short-lived. The late
1970s saw the rise oI the neoliberal economic model along with the recasting oI public health
and other social services within a market Iramework. As the neoliberal discourse in public
health policy became dominant Irom the 1980s onwards, the new buzzword became
"Selective Primary Health Care." Critics derided this new approach as "Health Ior $420 by
the Year 2000." The Washington Consensus doctrine oI an austere state rapidly superseded
the social democratic ideal oI government-Iunded programs to meet the essential needs oI
society. There was little room Ior ambitious public health programs.
No sooner did the WHO and its member states sign the Alma-Ata declaration than the debate
over Selective PHC created a schism in the global health community. WHO and UNICEF
the two main proponents oI PHC soon driIted apart, and UNICEF switched to promoting a
selective package oI low-cost interventions. The World Bank adopted the selective approach
Ior disease control in developing countries based on the rationale oI cost eIIiciency. Instead
oI viewing health as an integral part oI development, the Bank emphasized intervening at a
selective point in the epidemiology oI a disease or health system thus Iocusing on the
.3., determinants oI health rather than the social, political, and economic determinants oI
health that are largely beyond the control oI health ministries.
During this period oI structural adjustment programs, governments rapidly privatized many
state enterprises and incorporated competition into the provision oI social services. Many
poor countries slashed their health budgets and introduced user Iees in the healthcare sector.
The poor oIten had to make hard choices between Iood, education, or health care. As a result,
global poverty levels increased sharply Irom the late 1980s. Between 1992 and 2000, the
number oI hungry people increased by almost 60 million. And between 1985 and 2005, the
gap between average liIe expectancy at birth in low-income countries and in the major
industrialized countries actually widened by nine months.
Global Health Today
Today, although global health inequalities have become Iar greater than they were 30 years
ago, privatization and market principles remain at the center oI the international health
agenda. In recent statistics, the WHO reports that the diIIerence in liIe expectancy between
the richest and poorest countries still exceeds 40 years, and the cost oI health care has pushed
about 100 million people into poverty each year. As many as 5.6 billion people in low- and
middle-income countries have to pay Ior more than halI oI their health expenditure
themselves. Furthermore, the WHO estimates that an additional 400,000 child deaths per year
could be caused as a direct consequence oI the Iinancial crisis.
In other words, the ideals oI universal PHC, in which state capacities are strengthened to
ensure the rapid expansion oI Iree, publicly provided health care, appear to be Iurther away
than ever beIore. But the principles oI PHC are, in Iact, making a second resurgence.
Alongside the opening up oI intellectual space in the United States on the government role in
providing health care, a number oI civil society groups are exerting a push Ior PHC on the
international level. In December 2000, when governments were originally slated to meet the
Alma-Ata vision oI "health Ior all," the People's Health Assembly took place in Bangladesh
with over 1,400 participants Irom civil society movements and non-governmental
organisations. AIter more than a hundred sessions, the participants Iormulated The People's
Charter Ior Health, which soon became a common tool oI a worldwide citizen's movement
committed to making the Alma-Ata dream a reality.
On the 30th anniversary oI the Declaration oI Alma-Ata in 2008, the People's Health
Movement again reiterated its call. Meanwhile, in April 2008 the Ouagadougou Declaration
also called Ior a renewal oI the principles oI PHC and its implementation in developing
countries. A Iurther impetus was given to the concept oI PHC by the publication oI three
prominent reports in 2008: the WHO's World Health Report 2008, the WHO's Commission
on the Social Determinants oI Health (CSDH), and the Global Health Watch II.
OI these, the Iinal report oI the CSDH is oI particular note. Following a three-year
investigation, the CSDH reported that increased national wealth alone does not necessarily
increase national health. In Iact, economic growth can even exacerbate poor health unless
there is a Iairer sharing oI its beneIits. The structural drivers oI health inequality, stated the
Commission, are Iocused in the inequitable global distribution oI power, money and
resources, which demands a redistributive role oI governments to secure the social contract oI
public health. Some analysts considered the Commission's Iindings, peppered with stinging
criticisms oI globalization and trade liberalisation policies in poorer countries, to be little
short oI revolutionary.
The U.S. Debate
The divisive debate over national healthcare reIorm in the United States reIlects the
longstanding debate over "Health Ior All" on the international level. Critics on the U.S. right
Iear that universally provided medical care which could eliminate the role oI private
insurance companies in Iavor oI a government-only plan would be a radical intrusion oI
government into basic health services. On the other side oI the U.S. debate, advocates oI a
greater public role in health care argue that socialized medicine has long existed in the Iorm
oI Medicare, Medicaid, and the Veterans Administration all examples oI government-
Iunded single-payer systems that could be extended into a universal program. As outlined in
countless media commentaries over recent months, the Iully privatized U.S. health care
model has led to poor health outcomes compared to other advanced countries. The system
boasts the highest administrative costs, yet leaves 46.3 million Americans without access to
health insurance.
The public-versus-private debate on health care is similarly divisive on the international
stage. With the WHO's renewed commitment to PHC has come a reinvigorated notion oI the
public sector's redistributive Iunction and its ultimate responsibility Ior shaping national
health systems. Yet still the dominant global discourse Irames health care as a commodity
rather than a basic human right, with the role oI governments limited to supporting saIety nets
Ior those leIt outside a selective coverage oI healthcare beneIits. The World Bank in
particular continues to encourage and Iund the expansion oI private-sector health care,
despite a wide body oI evidence showing that only scaling up the public sector provision oI
services is likely to deliver health beneIits Ior poor people. Just as Republicans in the United
States staunchly oppose a strong central government role in health services, so do many
global health proIessionals continue to support private health systems over a tax-Iunded
public delivery oI health care in developing countries.
The United States is destined to play a pivotal role in the outcome oI these debates both on
the domestic and international scene. Many health proIessionals worry that the same
neoliberal thinking that contributed to the decimation oI health systems in the 1980s will still
prevail through U.S.-inIluenced institutions like the World Bank, IMF, and WTO. The U.S.
Agency Ior International Development is well known Ior supporting these same structural
adjustment programs, and today still leans toward market-based health systems and
privatization policies. U.S. Ioreign aid also continues to support only disease-based initiatives
that ultimately hinder the comprehensive health systems development central to PHC, despite
Obama recently calling his increased Iunding Ior combating HIV/AIDS, tuberculosis, and
malaria "a new comprehensive global health strategy."
While the three prominent reports released by the UN and civil society in 2008 signal a shiIt
in the right direction, a PHC strategy is still Iar Irom implementation. Although the WHO is
again attempting to Ioster PHC, there are no adequate global initiatives and no suIIicient
coalitions oI global institutions to address the social and economic determinants oI health.
Civil society has long criticized the WHO itselI Ior being too "disease-Iocused" and
supportive oI selective, vertical interventions that undermine its own PHC vision.
For many, the WHO's attempt to Ioster PHC is inadequate given the prevailing
macroeconomic order, in which private actors like the Gates Foundation spend more than
double the core budget oI the WHO on health care in developing countries. A basic criticism
oI the Foundation's work also concerns its bias toward biomedical and technological
solutions, and its business-oriented approach to health improvement that has Iragmented
health systems and diverted resources away Irom the public sector. As the WHO's CSDH
report concluded, technocratic solutions cannot resolve global health problems unless
combined with the political and power structure changes needed to redistribute economic and
social resources more equitably.
II the World Bank and international donors had tackled the structural causes oI ill-health by
adopting a comprehensive PHC strategy, as opposed to reinIorcing the privatized and
medical-technical approach to health care Iavored by the United States, the health catastrophe
in many developing countries would not likely have assumed such tragic proportions since
the 1980s. Still, we are at a diIIerent political point at this moment, when the stock market
collapse oI 2008 has led many to question "markets good, state bad" rhetoric. In light oI both
the renewed push Ior Primary Health Care and the crucial U.S. debate over healthcare reIorm,
the time is ripe Ior a global civil society movement to turn "health Ior all" into an
international priority.