Rift Valley

World Bank

 

Oxfam’s Briefing Paper No. 125 “Blind Optimism: Challenging the Myths about Private Health Care in Poor Countries” argues that “international donors are promoting an expansion of private-sector health care delivery” to meet global health goals and sharply criticizes the conceptual and practical arguments for working more with the private sector. Oxfam argues that “the evidence is indisputable… that to achieve universal and equitable access to decent health care … the public sector must be made to work as the main provider. There is no short cut and no other way.” In several important respects, this paper misrepresents the evidence on private health care in poor countries and the work of donors, including the World Bank, and draws conclusions more reflective of dogma than science. The following are some key points of disagreement.

 

 

 

Oxfam

 

Oxfam’s Briefing Paper No. 125, “Blind Optimism” was written with many contributions from academics across the world and was reviewed by a number of different actors who both sympathised and disagreed with the stance we are taking.  The evidence comes from Demographic Health Surveys; from peer-reviewed literature; from academics in research institutes globally; from our partner organisations; and from reports published by the World Bank, the World Health Organisation and donor agencies. In particular it draws heavily on the work of the WHO’s Commission on Social Determinants of Health, which concluded that reforms driven by international agencies and commercial actors that introduce market behaviour into public health systems and encourage a greater role for the private sector have further undermined the performance and ability of public health systems to redress inequity.   Above all the message of Oxfam’s paper is to call on the World Bank and other donors supportive of private provision to return to the evidence and themselves step away from ‘conclusions more reflective of dogma than science’.  

 

 

 

World Bank

 

1.      Oxfam states (p.2) “For over two decades the World Bank advocated a solution based on investment and growth of the private health-care sector.”

 

World Bank lending and non-lending work in the health sector is overwhelmingly focused on strengthening public sector health delivery. Lending is almost entirely to governments. The World Bank has repeatedly argued that, given the large presence of non-state actors in health, more could and should be done to leverage their potential contributions. This does not necessarily mean “growth” of the private health-care sector. Indeed in many countries the private sector in health may be too large, or parts of it that have poor quality, inefficiency, or impose a high payment burden may be too large. Improving the private sector can have a variety of different elements

 

Oxfam

Oxfam welcomes the World Bank recognition that in many countries the private sector in health may be too large, that scaling up ‘does not necessarily mean “growth” of the private health care sector, and that ‘parts of it [the private sector] have poor quality, inefficiency, or impose a high payment burden that may be too large’.  This is exactly the kind of reasonable assessment of private provision that has been lacking to date, and that our paper calls for.   Whilst criticism of the public sector is elaborate and detailed, our research identified no realistic assessments of both the positives and the negatives of private provision by the World Bank or any other major donor.  This makes a proper assessment based on evidence difficult.  As our paper demonstrates, the reality of private care in developing countries is that it is often either inaccessible to the poorest due to its prohibitive costs, or is of such a poor quality as to be in many instances dangerous to health.   

 

Oxfam recognises that the World Bank does indeed contribute to public sector health delivery through lending and non-lending (technical advice) to governments, and that World Bank health lending is predominantly through the public sector.  Indeed the conditions and technical advice attached to lending to governments gives the World Bank its unrivalled position in shaping the development policy of developing country governments in ways that have sometimes been damaging.  The introduction of health user fees in many instances, the systematic disinvestments in public services in favour of economic adjustment and debt servicing, and the hugely inefficient proliferation of vertical disease specific initiatives at the expense of investment in primary health and health systems have resulted in part from this influence. 

 

The fact that most World Bank lending goes through the public sector does not mean that it is not used to promote private provision.  In fact, as we outline in the paper, much of this lending and ‘non-lending’ (technical advice) is increasingly also being used to promote an approach which seeks to separate out the purchaser and provider roles, looking to the state increasingly as only a regulator and steward of the health sector while contracting out services to private providers.  In this approach, World Bank lending to governments is used to encourage governments themselves to contract out provision to private providers.  Our view is that this is a risky and largely unproven way to organise health systems and public services in developing countries, is not supported by the evidence, and can prove a dangerous distraction from the urgent need to scale up quality public provision.   

 

 

World Bank

2.      Oxfam states (p.2) “…publicly financed and delivered services continue to dominate in higher performing, more equitable health systems. No low- or middle- income country in Asia has achieved universal or near-universal access to health care without relying solely or predominantly on tax-funded public delivery.”

 

 We agree that most high health-performing developing countries have strong public sector delivery systems. However, we know of none that rely “solely” on tax-funded public delivery and are not sure what “predominantly” means. But we question the implied causality and the conclusions. Does tax-funded public delivery cause a country to become high performing, or are those countries with better governance able to make public sector health care delivery systems work (as well as other systems)? We believe the latter is the  correct conclusion and note that the number of developing countries able to do so is small and that there are far more examples of developing countries where  public systems still do not give satisfactory results despite decades of investment in such systems, often strongly supported by the World Bank and other donors.

 

What then is the guidance for donors and countries with poor governance in the public sector? Should they focus exclusively on tax-funded public delivery and hope for the best? Or should they seek more pragmatic approaches that build on what is available and what works in both the government and non-government sector to expand access and quality? Clearly we feel the latter is the right strategy. It is also worth noting as well that very few high performing developed countries rely solely or even primarily on government delivered services. (In the U.K. for example, GPs are not civil servants but private contractors to the NHS and hospitals are mainly non-profit trusts. Other rich countries have a wide mix of government and private roles in service delivery.) Why then be so dogmatic in prescribing only this approach for developing countries?

 

Oxfam

Oxfam welcomes the recognition by the World Bank that ‘most high health- performing developing countries have strong public sector delivery systems’.  Our starting point in developing the paper was predominantly empirical; a survey of those countries that have been successful, and an analysis of the policies they have chosen to pursue. 

 

Oxfam agrees with the World Bank that good governance and political commitment are indeed an essential pre-requisite for delivering health care to the entire population of any country.   Part of our work in over 100 countries around the world is supporting vocal citizen and civil society action to demand better governance. 

 

However, the evidence is that good governance is not enough to fully explain the success of high health-performing developing countries.  The policies they have chosen to pursue in health also make a major difference.  It is reasonable to suggest that given that most of them have chosen substantial public delivery of health services, that this method has the best chance of working in other developing countries. This does not mean that those countries have no private sector – they all do, and in many cases the private sector is comparably as large as neighbouring countries without strong public services. The difference is that those countries with strong and sustained investment in public provision are successfully delivering services for poor people, while those that don’t are not.  The fact that no successful developing country has chosen to rely predominantly on private provision instead of public provision certainly would suggest that the burden of proof lies very much with those who are advocating this route.    

 

 

Oxfam is clear that many developing countries have not managed to deliver the success of the few that have.  However, where we differ from the World Bank is that we do not feel that this means that there is some inherent or intractable weakness in public provision in these countries that means the private route is preferable.  The evidence does not show that the public route has failed, ‘despite decades of investment’, leaving no choice but to pursue private provision instead.   Instead the public sector in many poor countries has been decimated by years of under-investment and sapping of government revenues through debt servicing and low levels of very poor quality aid.  This was compounded by pressure to adopt now largely discredited policies such as the imposition of user fees (fees that remain in place in the majority of poor countries).  

 

None of this is to suggest that working with the public sector is not without many problems in developing countries, or that these services are not in a terrible state in many instances.  Neither do we suggest anywhere in our paper that donors and governments should ‘focus exclusively on public delivery’  - this is an inaccurate representation.  But as the increasing number of successful sector-wide approaches and initiatives such as the International Health Partnership show, it is possible in a wide variety of developing countries to get behind one government plan to expand access to health, and that the opportunities for scaling up quality free public provision are greater now than they have been for many years. It is for this reason we have released this paper now, to encourage donors to support the policies that have the best chance of working for a successful scaling up of health care in developing countries. 

 

 

World Bank

3.      Oxfam’s arguments about the not-for-profit private sector (“civil society providers”) are inconsistent and confused. Oxfam praises CSOs for “not being motivated by profit” and for being “a lifeline for many.” Yet Oxfam criticizes evidence from recent impact evaluations that CSOs sometimes provide better access and quality at lower cost than government services.

 

This growing body of evidence that governments can effectively contract out services to improve results is largely dismissed and we believe Oxfam ignores high quality evidence to reach this conclusion. According to Oxfam “CSOs must only ever be a complement to and not an alternative to, public health systems.” We are unsure what Oxfam means by this. If it means that public and private (including non-profit) provision should co-exist in systems – we agree. But if it means that CSOs can only provide services as an adjunct to in-place public sector delivery capacity, we disagree.  Experience shows that CSOs have enabled governments to finance alternative strategies of service delivery where governments themselves may be unable to deliver services. Most of the relatively modest financing from the World Bank for working with private providers has been of this type (not primarily support the private for profit sector as Oxfam implies) – assisting governments to contract out service delivery to accelerate health gains when government provision has not been able to meet the needs – and we anticipate doing more of this. Governments often recognize the advantages of this approach of using non-government providers as an alternative vehicle of health care delivery.

 

Oxfam

Oxfam is clear that non-profit or civil society providers are a lifeline for millions of people and are not subject to many of the market failures that disadvantage for-profit providers. But we also recognise that performance, capacity and cost-effectiveness vary across civil society organisations. In some countries the rapid growth of NGOs providing services has undermined the co-ordination of the health care system and has left some regions without any services at all. Non-profit organisations can still compete with the government for already limited numbers of health workers. That is why we are encouraging non-profit health care providers to sign up to the NGO Code of Conduct for Health Systems Strengthening to ensure their services do not undermine but support government health care provision. Existing non-profit provision where appropriate should be integrated into the national health system to ensure co-ordination and avoid duplication.

 

We do not agree with the World Bank that the evidence on contracting out provision to private providers is of a high quality. In fact we have very serious concerns about the quality and reliability of the data, especially in countries such as Cambodia and Bangladesh, and the way some World Bank advisors have used this data to promote contracting elsewhere. There are no fair comparisons we have found where donor agencies and government dedicate the same level of expertise and resources to strengthen public provision as compared to contracted private provision. Existing World Bank research has also avoided calculating the significant transaction costs associated with contracting. There is a need for more transparency in the analysis. Furthermore, any attempts to simply apply the findings of contracting with non-profit providers to promote contracting with very differently motivated and resourced for-profit providers is a serious mistake. 

 

The World Bank’s focus on contracting is to the detriment of exploring other ways in which not-for-profit organisations can support and expand health care provision. In Timor-Leste for example, NGOs played a critical but temporary role in rehabilitating the public health system and working in partnership with the government to build its capacity to manage and deliver services itself. The World Bank played a leading role in co-ordinating donors in support of this successful approach, and it would be great if this could be disseminated more widely. 

 

 

World Bank

 

4.      Oxfam emphasizes a polemic approach to the insufficient and highly mixed evidence about the performance of both the public and private sectors, emphasizing only mainly negative findings about the private sector.

 

We feel that overall the evidence is inadequate for such strong generalizations. Evidence on quality in general and evidence that properly compares public and private sector providers is particularly lacking. Rather than sterile and inadequate debates about which system is better, we prefer a more pragmatic approach especially in countries with weak public sector systems. We need to gain more understanding not only of how different strategies for service delivery perform but of why they perform the way they do and the relative benefits and costs of different strategies for increasing effective coverage with priority services. If working with the private sector will improve outcomes more than dogmatic strategies to expand poorly performing public sector delivery, we think it merits support.

 

 

Oxfam

Oxfam welcomes the fact that the World Bank recognises that ‘evidence on quality in general and evidence that properly compares public and private sector providers is particularly lacking’.  It is for this reason that we researched and wrote this paper, and hope that it will contribute to the process of addressing this research deficit and enable a much more evidence based debate.  

 

The World Bank itself has contributed to this research gap.  Research by the World Bank into the failures of the public sector, for example into its capture by the middle classes, or absenteeism of nurses and doctors, has been elaborate and detailed.  At the same time documentation or analysis by the World Bank or any other donor of public sector success stories and of private sector failings is sorely lacking, as are comparative studies.  Until we see this evidence deficit addressed, we believe that a truly ‘pragmatic’ approach is not possible, and any pretence to pragmatism is unfairly biased against public provision.  Given finite resources, the risk of pursuing the wrong policies in this evidence vacuum is deeply concerning.  We look forward to the World Bank working with others to address this research deficit rapidly in the coming period, so that the debate can be more evidence based.   

 

World Bank

5.      Oxfam argues that the public sector is the key to equity in access to health care.

However there is very mixed evidence about the equity performance of the public and private sectors. Recent work by the World Bank in its “Reaching the Poor” program, including extensive analysis of the Demographic and Health Surveys, shows a large disparity between the poor and the better-off in coverage with priority services including from public sources. For a number of priority health problems – treatment of children’s acute infections for example, private providers may deliver a larger share than public in reaching the poor. Public sector services may be captured by the non-poor and private providers may be the main source of service to the poor where public systems fail. This does not mean there are not significant problems with private provision. We feel it is useful to think in terms of both access and quality and ask whether creating new access (say to public provision) is necessarily or always better than improving quality of existing access (say to non-government provision).

 

Oxfam

The issue of equity of access is addressed in our paper at length, and also extensively by the IMF and in the recent report on the Social Determinants of Health.  The IMF is clear that even in situations where the middle classes capture more of the benefits of health provision, the fact that they pay more taxes means that the overall impact on society in most instances is still to increase equity.   In the majority of developing countries public health care still has to be paid for and user fees are still in place; it is no real surprise then that the better-off capture more of the services available.  This is why Oxfam, along with many others is calling for the World Bank to help eliminate user fees in all developing countries.

 

Oxfam’s paper does not suggest that there should be no attempt to make private provision work better for the poor.  In Malawi for example, we support the negotiation of agreements between governments and mission hospitals to make their services free. We support pragmatic approaches that build on equitable foundations. We also think that regulating and organising the multiplicity of private providers is in many instances a Herculean task that even developed country governments struggle with.  

 

 

 

At the same time the rapid expansion of public provision is not even being discussed in most country contexts. This is despite empirical cross-country evidence from Asia that equity in health care access is determined by what the government does or doesn’t finance and deliver, whilst the role of the private sector has negligible impact. We need to urgently redress the balance of emphasis if we are going to successfully scale up, and that is the main message of this paper. 

 

 

World Bank

6.      Oxfam raises some difficult questions about the role of the private formal and informal sector providers and specifically criticizes the recently established AMFm.

 

As in other places in the paper, Oxfam holds to the idealistic notion of free, universal, and good quality public provision and capable government regulation as the remedy to the problems of pluralistic health care delivery and lack of quality control in the non-government sector. Unfortunately, the evidence to assure us about the feasibility of this remedy in many countries is not there. Despite free public provision, people, including the poor, in many settings use a mix of government and non-government health care providers. Specifically with regard to artemisinin, our last effective drug against malaria, should we wager its efficacy solely on the hope that public systems will be effective and preferred in many difficult settings? Or should we seek a range of strategies to try to sustain effectiveness?

 

Oxfam

Our paper does not shy away from the many difficulties and problems with public provision in many developing countries. However, there is already a substantial and detailed body of evidence detailing public sector failings, but almost no assessment of the public sector successes that we identify in our paper, or what can be learned from them.  At the same time there is virtually no research undertaken by the World Bank or others looking at the failings of private provision, or a realistic assessment of the ability of governments to regulate or control private providers. In our paper we have tried to redress this balance, by looking in more detail at the available evidence in favour of private provision. 

Regarding the AMFm (the proposed scheme to subsidise private provision of Malaria drugs), we are particularly worried about repeating the mistakes of the past, where over and under-prescriptions of Chloroquine led to widespread drug resistance.  Already resistance to Arteminsinin has been found in Cambodia.  Given this is, as you rightly point out, ‘the last effective drug we have against Malaria’, risking its distribution by unqualified shop-keepers with minimal safeguards we feel is a mistake.  The AMFm also ignores research by organisations such as Médecins Sans Frontières showing how subsidisation of Artimisinin is not enough to significantly increase access to treatment for the poor. Their direct experience in countries across Africa has shown that it is only when completely free care (medicines, consultations and other related costs) was introduced that access rates dramatically increased. 

 

 

This does not mean the private sector should have no role in the provision of this medicine, particularly the faith sector and not-for-profits, in the same way the public and private sectors are working closely together to enable access to ART for those with HIV.  However, once again we feel the option of strengthening  public sector channels of delivery, including the use of community health workers and mobile clinics is being neglected in the rush to pursue private sector strategies, in this instance as a result of research that is weak. 

 

 

World Bank

7.     The informal private health care providers pose some particularly difficult problems. 

 

They are widespread, easily accessible, and popular. They are often of very poor quality. We think they have a role to play, but more evidence is needed on how to help governments work with them to improve access, quality, and coverage.

 

Oxfam

Oxfam remains concerned that the World Bank retains such an upbeat assessment of the informal private sector, especially in contrast to its damning assessments of public provision.  The informal private sector, is too often a shop-keeper, selling out-of-date drugs or an otherwise unqualified individual.   Too many informal private providers are a danger to public health in too many instances and cause untold misery to millions with false diagnosis and mistreatment every day. 

 

This does not mean that regulating or working with these providers is impossible, but there is no doubt that it is an enormous task, and should be realistically weighed up with the costs of expanded public provision, and the competitive pressure this will put on private providers to improve their standards, as has been the case in countries such as Sri Lanka.  Improving the standards of the informal private sector will also  necessarily involve limiting services to only those that can be delivered safely by unqualified practitioners. Informal sector interventions therefore cannot substitute for building and expanding comprehensive primary health care provision backed by an effective referral system for more complex treatment and care. This is critical if we are to reverse the appalling progress made to date on reducing maternal morality rates. 

 

World Bank

8.      Oxfam states (p. 27) “The World Bank and IMF, as well as some rich country donors have, through their aid and policy prescriptions, significantly hampered the ability of government to provide health for all” and that “ …failed policies, were a significant cause of government failure to deliver in recent decades.”

 

We are at a moment of increasing and unprecedented consensus amongst partners in global health about how to accelerate health gains towards achieving the MDGs. We doubt that the Oxfam paper, with its weak analysis, is a helpful contribution.

 

Oxfam

Oxfam would agree with the World Bank that there is indeed an unprecedented consensus amongst partners in global health about the need to scale up services fast to meet the MDGs.  We would also agree that there is consensus on a number of policy areas, for example the need to invest in health systems and rationalise the hugely inefficient and Byzantine proliferation of vertical health initiatives.  However, there are also very fundamental differences of opinion as to what policies will work best to rapidly scale up health in developing countries, both in terms of financing and in terms of provision.  Private financing and private provision have not been scrutinised or researched nearly enough to warrant the level of support they receive. 

 

With countries as diverse as the US and China planning significant scaling up of public financing and provision in health, and a fundamental recognition globally of the failure of the market in delivering equity, there is a need for the World Bank to move with the times.  Given finite resources and a worsening economic picture we cannot afford to waste a single dollar pursuing policies that are risky and largely unproven.  Instead we need advice and support on policies that have a track record of success at reaching poor people with systems that work for all.

Health activists are facing issues of privatization and commercialization of medical care and other essential services like water and sanitation everywhere around the world. In places where there is not universal access to care, including the United States, the question for debate is: What role(s) should private entities – meaning businesses and non-profits of various kinds – play in scaling up coverage? Where countries have achieved universal coverage, they face constant pressure to make their systems “more efficient” through increased private sector involvement through contracting and other means. 

This past week, the People’s Health Movement and Oxfam International participated in two Washington, DC events focusing on how beltway institutions like the World Bank, the International Finance Corporation (IFC, the private sector arm of the World Bank), USAID, etc., promote involvement of the private sector as the key to scaling up health care. The occasion was the release of the Oxfam briefing paper Blind Optimism: Challenging the mythsabout private health care in poor countries(http://www.oxfam.org/en/policy/bp125-blind-optimism)and PHM’s Global Health Watch 2 (http://www.ghwatch.org).  Oxfam’s paper and “Health and Education for All” campaign are part of what PHM’s Francoise Barten calls “a radical newapproach to global health” (http://www.thebrokeronline.eu/en/Dossiers/Special-report-Health-for-all/From-Alma-Ata-to-Almaty).

 

Despite major advances in knowledge and unprecedented gains in global wealth, health inequities between the rich and poor are increasing, both within and among countries. Poverty, poor living and working conditions and the inability to influence these conditions are directly related to poor health. The 2008 reportof the World Health Organization’s (WHO) Commission on Social Determinants of Health observes that ‘social injustice is killing people on a grand scale’.

 

The WHO report is one of three recent publications [my note: the Commission on Social Determinants of Health report, the World Health Report 2008 and Global HealthWatch 2] that highlight the urgent need to improve universal access to healthcare by means of a new approach to health. This approach, which is gaining momentum among specialists worldwide, involves addressing health issues in a comprehensive way – with a focus on systems instead of sectors – and tackling head-on the socio-economic causes of poor health and health inequity. 

While many people would say that this approach is not actually “new,” one of its tenets is that it is the role and responsibility the public sector – government – to ensure that people have the basic services needed to maintain health, and to promote economic policies that benefit everyone and decrease poverty. This contrasts with the mainstream mantra that government is inherently incompetent and inefficient, while business and “the market” are inherently efficient and effective. This questionable notion has become dominant over the past 30 years despite the fact that no country has achieved universal health care without government playing the principal role infunding and a major role in provision of care and regulation of both for-profit and non-profit participation in the system.

This contrast was evident at thefirst of the two DC events, a debate at the World Bank between (left to right in photo):

Guy Ellena, Director, Health andEducation, International Finance Corporation

Anna Marriot, Health PolicyAdvisor, Oxfam GBDr. Mukesh Chawla, Health Economist and Sector Manager, Health, Nutrition, and Population Department, World Bank

Stephan Nachuk of the Rockefeller Foundation (moderator)

Gina Lagomarsino, ManagingDirector, Results for Development InstituteDr. Ravi P. Rannan-Eliya, Director, Institute for Health Policy, Sri LankaDr. David McCoy, People’s Health Movement 

The Oxfam paper was released in part to respond to an IFC report, The Business of Health in Africa:Partnering with the Private Sector to Improve People’s Lives (http://www.ifc.org/ifcext/healthinafrica.nsf/AttachmentsByTitle/IFC_HealthinAfrica_Final/$FILE/IFC_HealthinAfrica_Final.pdf).Sponsored by the Bill and Melinda Gates Foundation and researched by McKinsey& Co., the report came with the announcement that the IFC will mobilise $1billion in equity investments and loans to finance the growth of private-sector participation in health care in sub-Saharan Africa. About half of the report’s 109 pages are a series of annexes giving examples of successful business models and a methodology for market sizing. If you don’t bother to read them, then you get the idea that the report is promoting all non-state actors, including non-profits and social enterprises. But the annexes clearly show where the profit potentialexists.

The essence of the arguments presented by the pro-private side at the debate were the following:

• We need to take a pragmatic approach (as opposed to an ideological approach) and do whatever works to scale up health care services.
• The private sector (including all non-government actors)  already plays a major role in health care financing and delivery in Low and Middle Income Countries (LMICs), and already serves the poor, so it makes sense to focus on it in the scale up process.
• “While not seeking to detract from the role of national governments in delivering health care, the health of the region’s inhabitants would be improved through a more formalized, integrated, regulated, and better capitalized private sector.” (The Business of Health in Africa)
• Governments are asking for help in developing the private health care industry, we don’t promote it. 

The pro-public sector arguments were:

• Most private sector provision of care in LMICs, especially that accessible to the poor, is through unregulated, informal for-profit shops and providers with little potential to provide a substantial amount of quality care. Oxfam has produced a short video about these services.  http://blip.tv/play/gaY47KwIiuRf
• No countries have achieved universal access to care without government being the principal funder and provider, and without strict regulation of the private sector. There is no evidence that even the “responsible” private sector reaches the poor – only governments have done this.
• Regulation of the private sector requires the same strengthening of governmental capacity as providing medical and other services. Development agencies should focus on increasing government capacity as funders, providers and regulators of health care.
• Despite statements to the contrary, the real goal of the IFC and its paper, and the push for “public-private partnerships” in general, is not to promote health for all though expanding the private health care sector, but to promote business opportunities and profit generation in the health care sector. 

The private sector promoters have repeatedly mischaracterized the Oxfam position during the debate and infollow-up blogs (http://blogs.cgdev.org/globalhealth/2009/02/oxfam_this_is_not_ho_1.php) as saying that development organizations should ignore the unregulated private sector. Anna Marriott addressed this specifically in her presentation and follow-up remarks. “Our … conclusion, again based on current evidence that no developing country has achieved universal access with predominantly private provision, is NOT that the private sector doesn’t have a role to play.  Again I have to challenge the characterization of Oxfam’s position on that.  But that the priority, majority focus of donors and developing governments efforts and resources should be dedicated to rapidly expanding and strengthening free government health care as the most costeffective and sustainable strategy.”

Ravi Rannan-Eliya bolstered thepro-public argument with data comparing countries that have expanded coverageand improved health indicators with those that have not. He showed that theprivate sector did not play a role in raising access for the poorest. The slide below, for example, shows that publicly employed skilled birth attendants makethe difference in serving the poorest women. The pro-private side presented noevidence other than a few pilot projects, yet claimed that a “formalized, integrated,regulated, and better capitalized private sector” improves the poorest people’shealth. As Ravi concluded, “There is no historical evidence that you can scaleup in the poorest countries and achieve universal coverage with privateprovision – even publicly financed.”

 

 

This is the main point, and even Guy Ellena from the IFC admitted it: 

“Well, Anna, come on. You’re showing us great hospitals and then people basically barefoot selling most likely counterfeit drugs. You know, you separate the world into a kind of world of opulence and a world of total misery. It is not the world we are living in. And not, the African world is not like that. You have very poor people that neither the public nor the private sector is reaching, that have no revenues, are not integrated into economic activities, have no jobs and are very, very difficult to reach whether it is public or private. And nobody is saying that, ok, this is going to be solved by the private sector.”

He then went on to say how “a lot of solutions are offered”to the rest of the population above the very poor. This is an expression of the“bottom of the pyramid” strategy that corporations must employ in order to continue to increase their rate of return now that they have hit their limit in the richer countries. If you can get each of the 4 billion people living onless than $5 a day to spend $1 a year on your “solution,” that’s 4 billion dollars in revenues. Of course, we are not after a few random solutions. We need comprehensive primary health care based health systems. 

The discussion was hindered by rhetorical arguments, such as: “We’re for doing what works, but you’re being ideological,” and the use of imprecise terms like “private sector” to include a wide range of actors with different goals and varied access to power. Dave McCoy from PHM tried to clarify this by distinguishing the impacts of different private health sector actors, and by placing the current popularity of “public-private partnerships”in the historical context of 30 years of neoliberal economic dominance. When he identified as an unproven assumption the idea that government is inherently inefficient and incompetent, this led to more accusations of “ideology.”  In addition to critiquing much of the research done on this question (and one thing everyone seemed to agree on was the need for more, better research on the private sector, although I believe we’ve known enough to provide health for all since at least 1978), Dave McCoy also recognized the need for discussion to go beyond the research and examine the normative values underlying the various points of view: What is an acceptable vision for what good health systems look like, and what role should government take? Which health activities should be profit generating which not? Are health services goods that should be marketed or human rights? 

The next day, PHM and Oxfam hosted a meeting of NGOs to discuss the Oxfam paper, the vision for public health systems strengthening, and what Washington, DC-based NGOs can do to advocate for the “new approach to global health.” For several years, PHM-US has recognized the need to build an advocacy circle of progressive health NGOs in the DC area. This group would coordinate resources and advocacy efforts directed toward beltway institutions like World Bank, USAID, US government, and others with large health impacts internationally. This meeting will hopefully be a first step toward itscreation. 

Wendy Johnson from Health Alliance International chaired andpresented the NGO Code of Conduct for Health System Strengthening (www.ngocodeofconduct.org).

“… a response to the recent growth inthe number of international non-governmental organizations (NGOs) associatedwith increase in aid flows to the health sector. (…) The code serves as a guideto encourage NGO practices that contribute to building public health systemsand discourage those that are harmful. The document was drafted by a coalitionof activist or service delivery organizations, including Health AllianceInternational, Partners In Health, Health GAP, and Action Aid International. 

After active discussion, several avenues for future action emerged: 

1.    Engage in advocacy with donors, international institutions andUS policy makers (perhaps especially important in light of the upcoming revision of the 1961 Foreign Assistance Act).

2.    Support civil society in developing countries to engage incountry-based advocacy with their own governments and donors.  

3.    Help Oxfam and others better understand how donors are supporting private and public sector actors on the ground by gathering stories/information.

4.    Conduct or support academic research to better understand donor preference for private sector health initiatives, and to compare private and public sector health performance regarding access, equity, cost, efficiency, scalability, etc.  

5.    Join the host organizations’ efforts and endorse the Code of Conduct.

Our next opportunity to meet in Washington will be around the Doctor’s for Global Health Assembly (www.dghonline.org), July 31^st-August2^nd, at George Washington University. For more information about joiningthe DC advocacy coalition, send an email to phm@turiano.org

 

 

Around the world, people’s health is threatened by the commodification of health services and resources that should be held in common. Countering the dominant models of health in development, design and evaluation of health care systems, and health policy, the concept of health as a human right (RTH) offers a profound critique. As noted by Paul Hunt, the United Nations Special Rapporteur on the Right to the Highest Attainable Standard of Health, in his annual report, it has only been six years since an authoritative understanding of the right to health emerged when the Committee on Economic, Social and Cultural Rights adopted general comment No. 14.

Since then some progress has been made in the development of a health and human rights movement. A few governments have integrated the right to health into their policies. UN health-focused agencies have been using the RTH in their work, and a number of health-related human rights cases have been decided at the national, regional and international levels. In academic circles, literature and courses on the RTH have multiplied. The growth of the recognition of the RTH in civil society has been particularly dynamic, though uneven, with some mainstream human rights organizations, health professional organizations and other NGOs explicitly adopting a RTH approach to their work, and others ignoring or rejecting it.

The People’s Health Movement has played an important role in the growing health rights movement, bringing together many of the organizations adopting the RTH perspective. Recognizing its key position in the movement, and the urgent need to operationalize the RTH, PHM has launched a global initiative to strengthen the RTH with a focus on the right to health care, the “Right to Health Care Campaign” (RTHCC).

PHM struggles for and demands the respect of all aspects of health rights, but this Campaign will primarily promote a health care as a human right discourse. It is not strategically possible for PHM to launch a global campaign encompassing all health determinants, but PHM as a whole will also support specific international campaigns on particular health determinants other than health care (e.g., the right to water). These campaigns take place in the context of a full spectrum of other PHM activities including research on primary health care and the social determinants of health, advocacy at international institutions like the World Health Organization and the World Bank, national level advocacy work by PHM country circles, and networking and solidarity actions.

There are, at this moment, several important challenges and opportunities for the health rights movement that our campaign addresses. Among the difficulties of the humanRights-based approach to health, according to Yamin (Yamin, Alicia E. 2000. “Protecting and Promoting the Right to Health in Latin America:Selected Experiences from the Field.” Health and Human Rights 5, no. 1: 116–148.), are a lack of consciousness among the world’s populations about health as a right, the problem of enforceability under international law, and a lack of consensus on what such rights mean in practice. PHM’s campaign tackles these issues from the bottom up, by engaging grassroots health workers, community activists, and citizens in learning about human rights and the right to health via participation in an evaluation of the state of the right to health care at the country level. In phase I of the campaign, PHM will carry out about twenty country participatory assessments of the status of the RTHC.  The assessment guide designed by PHM for this process can be viewed at http://www.phmovement.org/files/RTH_assmt_tool.pdf PHM activists will document violations of the right to health care and will analyze important health determinants locally,  then plan joint actions with rights holders and duty bearers to stop these violations. This process will raise awareness and understanding of the right to health and will stimulate a right to health discourse among those facing the daily realities of the local, national and global level crises of the health system. The development of activist strategies to address health problems defined from the health rights perspective will create new modes of accountability, and will contribute to the understanding of social rights in practice.

In Phase II of the campaign, participants in the national assessments will be linked to a global process of mobilization to operationalize the right to health. In a series of regional assemblies, the participating country circles, and regional and global strategic allies, will meet to share results of assessments and action plans; to facilitate a dialogue between PHM and partners with the national health policy makers on implementation of health rights and related health system improvements; and to make recommendations for how the PHM global organization and its allies can support national demands for compliance with RTHC commitments, for example, via action at WHO or other multilateral institutions, or international solidarity activities.

The third phase of the campaign is the implementation of these plans. The timing of the campaign is concurrent with the build up to the 30^th anniversary of the Alma Ata Declaration,  which should present opportunities for public outreach and participation in fora that would otherwise not exist.

See www.phmovement.org for more information about PHM and the campaign.

If you haven’t considered coming to the US Social Forum (June 27 - July 1, 2007  Atlanta, GA www.ussf2007.org), or if you aren’t sure if it will be worthwhile, PHM is working with many organizations to present excellent events on health and health care in the US. This is a great opportunity to raise the PHM perspective with national and local groups working on health related issues, and to work toward building greater unity of vision and strategy among US health and health care organizations. We encourage everyone to come. Here are some of the highlights:

“Promoting Health for All,” an International People’s Health University short course will be held from June 27-30,
2007, in conjunction with the US Social Forum. Each day of the IPHU includes two hours of presentations by faculty followed by two hours of discussion and activities. Afternoons and evenings are free for exploring the hundreds of workshops and presentations at the US Social Forum and networking with other leaders and activists.
Topics will include:

• Healthcare as a human right not a commodity to be bought or sold
• Socio-economic, racial, and gender inequalities as barriers to health and healthcare within the United States
• Connections between health, trade, agriculture, and war
• The global movement for equal access to health and healthcare
• Practical skills for transforming knowledge into action

See details and application at www.phmovement.org/iphu

Workshops and panels PHM has organized or contributed to:
2838 Defending Our Water and Protecting Our Food: Bringing Family Farmers and Water Rights Advocates Together
2841 Our Bodies, Our Water: Our Right to Safe Water and Health
3005 A human rights approach to health advocacy and activism
3177 Health for All: a people’s vision for health and justice
3419 Access to essential medicines: advocating locally and globally
3916 What Is Social Medicine?
840 A People’s Healthcare Truth Hearing
 
See all the sessions submitted at http://www.ussf2007.org/en/submitted_proposals

Other activities:
Wednesday, June 27th - Health organizations will march together in the opening march.
Thursday, June 28th - Health and Healthcare day in the PPEHRC tent
Friday, June 29th, 3pm - “March for Our Lives” to CocaCola headquarters for the Right to Water
Ongoing - Working with Healthcare NOW, volunteers will take testimonies from people who have been affected by lack of health care and in favor of HR 676, the expanded and improved Medicare for all bill sponsored by John Conyers. Volunteers are also needed for petition signiture gathering for HR676.
 
Let us know if you are planning to attend or if you would like to help. Contact Zena at zena@hesperian.org

Dr. Halfdan Mahler of Denmark served as Director-General of the World Health Organization from 1973 to 1988. Under Dr. Mahler’s leadership, WHO launched the “Health for All by the Year 2000” strategy following the Alma Ata Conference. Dr. Mahler continues to promote Health for All. He attended the first and second People’s Health Assemblies, and many other Peoples’ Health Movement  activities. In the letter below, sent to the second Indian National Health Assembly of the People’s Health Movement - India held last week in Bhopal, he challenges us to create a world in which the conditions that make health possible are available to ALL.

Dear friends,

The question that keeps being raised is: “Can health truly form a leading edge for social justice, especially when we are dealing with situations where the basic issue is survival; where people are tapped in the vicious circle of extreme poverty, ignorance and apathy?”

I can best answer this question by referring to the events that lead to the creation of the Health for All Movement and to this movement, in my opinion, becoming a leading edge in the promotion of equity and social justice.

The World Health Assembly decided in 1977 that the main social target of governments and WHO in the coming decades should be the attainment of what is known locally and globally as “Health for All.” The World Health Assembly described that as a level of health that will permit all the people of the world to lead socially and economically productive lives. Please note that the World Health Assembly did not consider health as an end in itself, but rather as a means to an end. That end is human development, as characterized by social and economic productivity and well-being. You will also note that the social aspect preceded the economic aspect. That is also as it should be. When people are mere pawns in an economic growth and profit game, that game is so often lost for the poor. But when people themselves can contribute actively and voluntarily to the social development of the society in which they live, whether in such fields as shaping public policies, providing social support to others, undertaking voluntary action for the health and education of society, or through all kinds of spiritual and cultural activities, in other words when people are socially productive there is much hope for economic productivity too.

This morally binding contract of Health for All was the basis of the Primary Health Care strategy which implied a commitment not only to a reorientation of the conventional health care systems–which rather should be called “medical repair systems”–but to a radical shift towards people`s own control over their health and well-being… This implies a continuous empowerment process whereby people acquire the skill and will to become social carriers of their own health and well-being.

I believe that the fundamental values of social justice and equity are firmly imbedded in the vision of Health for All and the strategy of Primary Health Care. And this vision and strategy can indeed be strong forces and leading edges for achieving social justice and equity. Health may not be everything, but without health there is very little to individual and social well-being.

But, most importantly, Health is Politics and Politics should be Health as if ALL people truly mattered. And the Peoples’ Health Movement in India must be the permanent conscience of such politics in your wonderful country. In realizing this oh so difficult conscience role I admire you for having found in the Human Rights paradigm the cumulatively energizing support of this role. We must not let today’s local, national and global injustices take over. Indeed WE MUST NOT.

With my warmest thoughts and good wishes,

Your friend and admirer,

Halfdan

For years in developing nations, international aid agencies and multilateral organizations have defined the health services that are provided to poor communities by what they fund, and by requiring structural changes in government services as conditions for loans. These programs have emphasized maternal/child health, malaria, HIV, tuberculosis, and a few other diseases, with limited input from local beneficiaries or providers into these priorities. But among the consequences of health programs designed by people from outside of the communities they serve is that they don’t address the community’s real needs.

The leading cause of death among adults in the municipality of Jiquilisco on El Salvador’s coastal plain is unrelated to the priorities of aid agencies and the World Bank. Chronic renal insufficiency, not associated with its usual causes, diabetes and high blood pressure, has been diagnosed in 30-45% of men over 30 — and there are few resources directed toward the prevention, early detection, or treatment of this disease. In 2005 a community organization, the Fondo Social de Emergencia (Emergency Social Fund) identified 23 deaths from renal failure. The Salvadoran Ministry of Health counted only one. In the first half of 2006, 12 people (11 men and 1 woman), in a population of about 40,000, died from renal failure.

Chronic kidney disease and renal failure are recognized as a growing problem throughout the world. In most places, this is due to lifestyle and dietary changes that have promoted an increase in diabetes and hypertension. Jiquilisco has experienced this same increase, but the large majority of those diagnosed with chronic kidney disease in Jiquilisco have had neither predisposing condition.

Jiquilisco is located in the region known as the Bajo Lempa (the lower Lempa River). From the 1940s through the early 1980s, people’s main economic activity was growing cotton for export on large plantations. Workers were exposed to high levels of a variety of agricultural chemicals and the shallow water table became heavily contaminated. The highest incidence of renal failure is among former plantation workers.

There is no treatment available for chronic kidney disease in the Salvadoran Ministry of Health clinics. According to Mirian Colindres, the nurse at the clinic in La Canoa, Jiqulisco, they never have ace inhibitors - the high blood pressure medication usually given to preserve kidney function. They rarely have any high-blood pressure medication at all. “For years the aid agencies and PAHO have emphasized maternal-child health, so that is what we have, medicine and supplies for women and children. But men and adults and old people live here too and deserve attention. If a father dies from kidney failure, his children won’t have enough to eat and then we’ll give them vitamins. It would have been better to treat the father.”

Once the illness has progressed to kidney failure, it is almost impossible to get hemodialysis. The Salvadoran Health Ministry has so few machines that new patients sign on to a waiting list - waiting for someone currently receiving dialysis to die.

The alternative to hemodialysis is peritoneal dialysis, a procedure in which the abdominal cavity is filled with dialysis fluid and toxins diffuse through the cavity membrane over several hours. In El Salvador, patients are not given supplies to perform this procedure in their own homes, a common practice in other countries. In any case, most patients cannot afford the extra charges the hospital levies for a permanent abdominal catheter. Instead, they must have their abdomen punctured by a temporary catheter every time they go for treatment - twice a week. Most give up after a few times, preferring to “die at home with the children and grandchildren around.”

Recent studies by nephrologist Dr. Ramon Trabanino and Instituto Municipal de Salud Publica de Barcelona have identified that this epidemic is, in fact, occurring all along the Pacific coast of Central America in areas of current or former export agriculture. These studies contrast coastal agricultural workers with subsistence farmers at higher elevations. In Mexico, Guatemala, Honduras, and El Salvador the results are similar. Men who have worked in export agriculture in the hot coastal zone, routinely exposed to agricultural chemicals, experience elevated rates of renal failure that increase with age. Most do not have the usual risk factors of chronic hypertension or diabetes. In contrast, the men from higher, cooler elevations have normal rates of renal failure.

Sugar cane workers in Chichigalpa, Nicaragua face the same epidemic. 2400 have died of renal failure since the year 2000. This small town is renowned as the center of Nicaraguan sugar and rum production since the founding of Ingenio San Antonio, one of the largest sugar cane plantations in Central America, in 1898. The Pellas family, owners of Nicaragua Sugar Estates, is one of the richest and most powerful in the region, but they have refused to assist their former employees. In fact, the workers were fired when they were diagnosed with the disease.

While El Salvador’s Health Ministry and other governmental agencies have neglected the problem, the community itself has begun to attend to its own needs. Founded by communities in Jiquilisco in the wake of Hurricane Mitch, the Fondo Social de Emergencia de Salud caught the attention of Dr. Trabanino and inspired him to conduct the research described above. He has helped the Fondo to organize low-cost kidney disease screenings, educated effected persons on what to demand from treatment, and has provided appropriate, standard of care treatment to some patients for no cost.

The Fondo is now educating the communities about the causes and prevention of kidney disease - advising farmers not to reuse agrochemicals containers for drinking water, to apply chemicals more safely, to use medications correctly, and to drink enough water to avoid daily episodes of dehydration. They have succeeded in attracting national media attention. The Fondo raises money through international donations and by asking every household to contribute 25 cents a month. Another local organization, United Communities of the Bajo Lempa has sought independent financing for a potable water project without the involvement of the government water authority. They organized work brigades to build a system carrying water from higher elevations so most of the area’s inhabitants no longer have to drink contaminated well water.

In spite of community efforts, the cause of the epidemic is still unknown. There is clearly an association with agricultural work and chemical exposure, but a specific agent (or agents) hasn’t been identified. Since the large growers and chemical manufacturers are controlled by the wealthiest and most powerful families in Central America, it is unlikely that any government affiliated body in these countries would undertake an epidemiologic investigation or recognize the liability of these businesses for their employees or customers injuries. The unregulated use of medicines, the overuse of pain medication, and other factors that cause a reduction in reserve kidney function may also play a role in the process that leads to an individual developing this condition.

Dr. Trabanino has tempered his initial suspicions regarding chemical exposure, and suggests that daily episodes of dehydration while working in extreme heat may be the cause. However, while dehydration has been identified as a cause of acute kidney failure (not chronic renal insufficiency), one would expect other conditions associated with heat and dehydration - heat exhaustion, heat stroke, and kidney stones - to be common if this were the cause. They are not.

Further complicating the picture are cases of men with chronic renal insufficiency who have lived in the area for less than 13 years and who were only minimally involved with agriculture. Mirian Colindres, the nurse quoted above, lost her brother to kidney failure two years ago, and her husband has CRI. They moved to Jiquilisco after the civil war ended and worked in small scale agriculture for only 1-2 years.

Beyond Central America, this epidemic raises many other serious issues:

For workers and their families: Is this epidemic occurring “under the radar” in other export agricultural regions? How can workers effectively demand that the cause be identified and appropriate prevention, screening, and treatment be provided? What other health problems are being caused in these areas by chemical contamination and dangerous working conditions?

For governments, health ministries and public health professionals: Will the epidemic be investigated? Will people receive the prevention, screening and treatment required? Will responsibility be assigned to ensure workers are protected from dangerous working conditions? Will companies and individuals be held accountable for negligence in the treatment of workers and marketing of products? Who will apportion responsibility among the national and multinational chemical and agricultural companies, and the wealthy nation consumers who purchase the sugar, rum, bananas, flowers, textiles and other goods produced with intense chemical inputs in developing countries? Will the multilateral organizations, aid agencies, and funders that claim “improving health” as their mission begin to include local communities in designing health programs?

For more information:

http://Fondosocial-emergencia.webb.be

http://72.14.203.104/search?q=cache:SlQqG6cUxIgJ:www.fluehi-ma.de/allgem/downloads/saludos_26.pdf+%22fondo+de+emergencia%22+lempa+blanca&hl=en&gl=us&ct=clnk&cd=4

http://www.prensalatina.com.mx/article.asp?ID=%7B1CA40CA7-BB2B-4193-92EC-37E91563599F%7D

http://www.elsalvador.com/noticias/2006/05/08/nacional/nac10.asp

http://www.elsalvador.com/noticias/2006/11/11/portada/index.asp

http://www.worldmag.com/articles/7474

http://www.lainsignia.org/2006/febrero/ibe_020.htm

http://hbar.phys.unca.edu/ncur20//abstract_display.asp?id=1867

http://www.scielosp.org/scielo.php?pid=S1020-49892002000900009&script=sci_arttext

http://www.inchem.org/documents/ehc/ehc/ehc119.htm#SubSectionNumber:2.5.6

The studies by Dr. Trabanino on chronic renal disease in Mexico, Guatemala, El Salvador, and Honduras are available from phm@turiano.org.

http://www.phmovement.org/en/campaigns/righttohealth

Contact, the publication of the World Council of Churches, has devoted an entire issue to People’s Health Movement and the July 2005 assembly.

http://www.phmovement.org/files/Contact_N._180_PHA2.pdf

The introduction by Claudio Shuftan is copied below:

A short summary of the People’s Health Movement will help put this Assembly into context for our readers. The PHM, a network of more than 300 base organizations in 80 countries worldwide, was born at the end of the 1990s and held its first international Assembly in December 2000 in Savar, Bangladesh. That meeting saw the launch of People’s Health Charter, the historic document that summarizes the ideological position of our network and has been translated into 45 languages. The Cuenca Declaration reiterates and updates the principles of this Charter.
The People’s Health Movement has garnered many achievements since its inception, including:
• active participation in the annual World Health Assembly of the World Health Organization
• collaboration, as co-author of the Global Health Watch study, launched in Cuenca (see page 19)
• key participant in the creation of the WHO Commission on Social Determinants of Health, and consultant to its upcoming report
• the Global Right to Health Campaign Initiative
• the launch, at the PHA2, of the International People’s Health University, to prepare future leaders of the movement.
The PHM is organized democratically in geographic and thematic circles. The voices of the PHM are spread through specific interventions by its members in diverse forums around the world and through its website: www.phmovement.org. Discussion and exchange also take place over an electronic listserve, open to all, at: pha-exchange@kabissa.org.
In Cuenca, the enthusiasm of some 1,500 active participants was palpable and contagious. The photos in these pages reflect this energy and the many voices presented here will transmit to the reader something of this excitement. Our thanks to the World Council of Churches who, in collaboration with Fundación EPES (Educación Popular en Salud) in Chile, produced this special issue of contact. Their efforts bring the reader an excellent synthetic and panoramic overview of events at Cuenca — not only its intellectual and political achievements, but also the spirit and hopes behind them.
This issue highlights:
• health as the outcome of the political and social determinants that generate it. It also reminds us that Primary Health Care has been betrayed and that a return to the vision of “Health for All” laid out at the 1978 Alma-Ata Conference is only possible through popular mobilization at the international level
• the right to health is a non-negotiable demand of all peoples and a key strategy of the PHM regarding the legal obligations of governments and international co-operation. The human rights strategy to health transcends the misdirected “basic needs” approach adopted in recent decades
• the disastrous impacts of the privatization of health services, with drastic cuts in social spending as dictated by neoliberal economic ideology. The PHM has publicly criticized the WHO for not taking a more pro–active position against privatization
• community efforts with the potential to bring structural change by fostering new awareness, hope, and direct action by the beneficiaries of health care
• the negative impacts on health of free trade and intellectual property agreements, particularly concerning the need for generic drugs and access to medicines
• the vibrant presence of indigenous people who understand the value of an intercultural approach to health. Respect for traditional health care is indispensable in any process of health reform
• the effects of war on non-combatants and the use of sexual violence as a weapon, as described in testimonies from Iraq, Palestine, Africa, Asia and the Americas, are unacceptable
• the links between the health of the planet and human health must be seen in the light of the over-exploitation of natural resources and new agricultural technologies.
Above all, these pages record how the People’s Health Movement creates and extends solidarity to all those who fight for HEALTH FOR ALL …NOW.

Here on the Hayward fault, the “big one” could come at any moment - at least there is a 70% liklyhood within 30 years. After Hurricane Katrina gave us a kick in the butt, we replenished our earthquake supplies (or finally got around to putting a 72 hour supply of food, water and blankets in a trash can in the back yard). CliffBar experienced a sudden spike in sales. Neighborhood emergency response trainings are scheduled all over town.

But, the most likely emergency situation we will experience within the next 3 years is not an earthquake, and this disaster will be global in scale and last for months. Yesterday I heard a fantastic interview with Mike Davis, author of The Monster at Our Door: The Global Threat of Avian Flu on the radio program Against the Grain (link at right). From their website:

The World Health Organization predicts a influenza pandemic in the next few years which could kill millions of people. As bird flu spreads to poultry in Europe the fear that the disease might mutate to become transmissable grows. Mike Davis talks about the ecological and economic factors that could lead to an avian flu pandemic.

One great thing about the interview is that it is completely unlike the inflammatory publisher comments you can read on bookstore sites: “Avian influenza is a viral asteroid on a collision course with humanity”!!!!!!!!!!!!!!!!  The interview manages to expand from avian flu to cover just about every significant issue in global and public health today - all in 1 hour.

Check out the interview. If you read the book, send me your comments. I hope to read it after I’ve finished stockpiling 6 months of food.

My techie geek nerd neighbor, Robert, encouraged me to start this blog as a tool for political organizing around the Right to Health. He will probably be one of the few people who ever sees it. He insists that, even though there are now millions of blogs out there, I will have more effect writing this than if I stood out on my front porch and yelled, “OK, listen up everyone! Time for Laura news!” We’ll see.

I have been doing some work with the People’s Health Movement since June of 2005, and I was recently asked to take on (that would actually mean “start”) the Right to Health campaign for the US. PHM is a global network of organizations and individuals promoting the idea that health for all is acheivable via a primary care and social justice strategy - http://www.phmovement.org/.

PRINCIPLES OF THE PEOPLE’S CHARTER FOR HEALTH 

The attainment of the highest possible level of health and well-being is a fundamental human right, regardless of a person’s colour, ethnic background, religion, gender, age, abilities, sexual orientation or class. 

The principles of universal, comprehensive Primary Health Care (PHC), envisioned in the 1978 Alma Ata Declaration, should be the basis for formulating policies related to health. Now more than ever an equitable, participatory and intersectoral approach to health and health care is needed.

Governments have a fundamental responsibility to ensure universal access to quality health care, education and other social services according to people’s needs, not according to their ability to pay.

The participation of people and people’s organisations is essential to the formulation, implementation and evaluation of all health and social policies and programmes.

Health is primarily determined by the political, economic, social and physical environment and should, along with equity and sustainable development, be a top priority in local, national and international policy-making.” http://www.phmovement.org/files/phm-pch-english.pdf

Through writing this blog I am hoping to clarify my ideas on this campaign, organizing, health and healthcare, and the social determinants of health. If anyone besides my neighbor reads this, their feedback and engagement with this site and with PHM is strongly encouraged.