Transcript Equity care in health : why have health economists had so

Challenging health economics and
neoliberalism. Community
perspectives
Gavin Mooney, Professor of Health Economics, University of
Sydney, Perth, Australia; Visiting Professor, Aarhus
University, Denmark and the University of Cape Town, South
Africa
Sundhed, Menneske og Kulturs 2. Nordiske Koneference i
Humanistisk Sundhedsvidenskab
Viden, Politik og Sundhed
Neo liberalism and health: another way
forward - or several?
• What is essential in every country is
that the ‘principle of hope’ should be
kindled in most human minds and
hearts … If it remains confined to the
hearts of punters in stock markets as in
India or if it dies out in many male
hearts as in Russia, the progress
towards a more humane and violencefree future will remain troubled by
obstacles.
Amiya Kumar Bagchi 2007
Outline of talk
• Neo liberalism and its problems
• Poverty, inequality and health
• Culture and health
• Global institutions and the current economic mess
• So let’s listen to the voices of the people as a
community, locally and globally
Neo liberalism
• ‘a theory of political economic practices that
proposes that human well-being can best be
advanced by liberating individual
entrepreneurial freedoms and skills within an
institutional framework characterized by
strong private property rights, free markets
and free trade … State interventions in
markets … must be kept to a bare minimum.’
Harvey 2005
Communitarianism
• Place value system into the hands of
the community qua community rather
than individuals
• Adopt a communitarian stance where
community values count and where
community per se is valued.
Key Points
• Maintaining the diversity of cultures is
essential to human health
• Such cultural diversity is best
supported through the diversity of
economic systems
Culture, health and health
services I
Different cultures:
• define health differently
• have differing impacts on health
• have different wants from health
services
Culture, health and health
services II
Indian construct of health
• It is holistic with great emphasis on
prevention … the body is comprised of
three primary forces, termed dosha.
The state of equilibrium between the
dosha is perceived as a state of health;
the state of imbalance is disease.
Bhungalia et al
Culture, health and health
services III
Eckersley’s ‘cultural fraud’ of neo liberalism:
• ‘the promotion of images and ideals of ‘the good life’
that serve the economy but do not meet
psychological needs or reflect social realities.’
•
‘To the extent that these images and ideals hold
sway over us, they encourage goals and aspirations
that are in themselves unhealthy. To the extent that
we resist them because they are contrary to our own
ethical and social ideals, they are a powerful source
of dissonance that is also harmful to health and wellbeing.’
Culture, health and health
services IV
• ‘The description of the identities and
values of a nation by the exclusive
labels of individualism and
communitarianism does not reflect
recent reality. The world in which we
live now is a complex blend of both
individualism and communitarianism.’
Frimpong-Mansoh (2007)
Culture, health and health
services VI
Naughty WHO (2000) World Health Report
• WHO used their criteria and their weights to
decide what the criteria are of a good health
care system … then applied them to all
countries.
• This is WHO elitist, universalist nonsense on
a global scale.
Neo liberalism’s problems for
health I
Examples
• Stealing of doctors and nurses
• Brazil
• Russia
Neo liberalism’s problems for
health II
Introduction of TV in the societies of the Dene
Indians and Inuit in the Arctic:
‘children lost interest in the native language
… they refused to learn how to fish on the ice
or go hunting … Young people did not want
to be Indians …they want to be Canadians
and Americans … Our traditions have a lot to
do with survival. Community co-operation,
sharing, and non materialism are the only
ways that people can live here [in the
Arctic]’.
Mander (1996)
Que faire? I
• Getting the theory right
• Getting the governance right
• Getting the economic systems right
Getting the theory right I
Hegel
• Issue of freedom supported by the
state and social institutions based in
culture
• Socialise people into good habits
Getting the theory right II
• In his conceptualisation of freedom,
Hegel emphasised the crucial role of
institutions ‘so that self-conscious
individuals could become more aware
of the meaning of the institutions in
which they participated – a step
towards feeling at home in these
institutions’
Getting the theory right III
Hegel (quoted in Avineri)
• ‘it is of the utmost importance that the
masses should be organized, because
only [by] so do[ing do] they become
mighty and powerful. Otherwise they
are nothing but a heap, an aggregate of
atomic units. Only when the particular
associations are organized members of
the state are they possessed of
legitimate power.’
Getting the governance right I
• ‘Democratic movements can learn from
experiments in participatory government that
have been conducted in far-flung locales. At
Porto Alegre in Brazil or in the states of
Kerala and West Bengal, people … have
experimented with decentralized,
participatory modes of governance.’
Bagchi 2005
Getting the governance right II
• Need to encourage individuals ‘to become
involved in collective efforts to improve the
structural determinants of health, such as
reducing the social inequalities in our
societies or eliminating the conditions of
oppression, discrimination, exploitation, or
marginalization that produce disease’.
Vicente Navarro
Getting the economic systems
right I
• best defence of diversity of culture is
diversity of economic systems
• not solely the neo liberalism of globalisation
that is the problem but the hegemony of neo
liberalism
• need to seek new forms of economic
systems and to build on those alternative
models that already exist.
Getting the economic systems
right II
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Cuba
Venezuela
the Scandinavian countries
Mondragon in the Basque region of
Spain
• Kerala in India
• Grameen micro credit banking system
in the sub-continent
Social Determinants of Health
Key issues
• Poverty
• Inequality
Inequalities
• The gap between rich and poor both
across the globe and within countries
has been increasing as a result of neo
liberal globalisation. In 1960, the
average per-capita GDP in the richest
20 countries in the world was 15 times
that of the poorest 20. This gap has
widened to 30 times.
Global Inequalities
• Today, the richest 20 per cent of the
world’s population has 86% of world
GDP; the poorest 20 per cent has 1 per
cent.
Problems with the existing
health economic paradigms
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Based on individual values
Consequentialist
Health care focus dominates
Assume common constructs of health
Do not allow for cultural relativity
Do not link cultural systems to
economics systems
Charles Taylor: The Malaise of
Modernity
• ‘the dark side of individualism with its
centring on the self, which both flattens
and narrows our lives, makes them
poorer in meaning, and less concerned
with others or society”
• Taylor does not write of global
concerns, but same issues arise
globally
Padarath et al 2004
• The lower the income of a country the
higher the proportion of the health care
spending that is private.
Doha Agreement I
• ‘International trade can play a major
role in the promotion of economic
development and the alleviation of
poverty. We recognize the need for all
our peoples to benefit … The majority
of WTO members are developing
countries. We seek to place their needs
and interests at the heart of the Work
Programme adopted in this
Declaration.’
Doha Agreement II
• ‘We are committed to addressing the
marginalization of least-developed
countries in international trade and to
improving their effective participation
in the multilateral trading system.’
Stiglitz 2003
• ’If the issue of access to AIDS drugs
were put to a vote, in either developed
or developing countries, the
overwhelming majority would never
support the position of the
pharmaceutical companies or of the
Bush administration.’
IMF and WB Voting
• IMF: the US has 18% of the vote,
Germany and Japan 5.5% each, France
and the United Kingdom 5% each, the
G-7 countries a combined total of 45%.
• WB: very similar
Conditionalities
• ‘the programmes would bind the borrower to
a set of conditionalities intended to bring
about sustainable budget deficits, monetary
discipline, competitive exchange rates, and a
general liberalization of the economy’.
Chakravarti 2005
• These conditions represent the imposition of
neo liberal economic reforms.
Global Institutions and Health
• The global institutions of the World
Bank and the IMF have considerable
potential to influence world poverty and
inequality and in turn improve health
and health inequalities across the
globe. They have chosen not to do so.
Impact of Neo Liberalism
• On growth
• On inequalities in income and health
• On culture
Current Economic Meltdown
• Reform looks like a ‘patch up’ job
• Radical revisit of Bretton Woods
needed
• Radical thinking on
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Size of fund
People versus governments voting
Market structures
Definition of Equity from
Citizens’ jury in Perth, Australia
• Equal access for equal need, where equality
of access means that two or more groups
face barriers of the same height and where
the judgment of the heights is made by each
group for their own group; where need is
defined as capacity to benefit; and where
nominally equal benefits may be weighted
according to social preferences such that the
benefits to more disadvantaged groups may
have a higher weight attached to them than
those to the better off.
Hegemony of neo liberalism
UNESCO on cultural diversity:
• ‘Globalization, in its powerful
extension of market principles, by
highlighting the culture of economically
powerful nations, has created new
forms of inequality, thereby fostering
cultural conflict rather than cultural
pluralism.’
Communitarian claims
• John Broome: a claim to a good involves a
duty that a candidate for that good should in
fact have it.
• Communitarian claims ‘recognise first that
the duty is owed by the community of which
the candidate is a member and secondly that
the carrying out of this duty is not just
instrumental but is good in itself’ (Mooney).
Commercial Break
More on communitarian claims?
READ MY BOOK!
Neo Liberalism Problems
• Globalisation based on neo liberalism
cannot support social justice.
• Fiddling with neo liberalism while the
world's poor burn is no solution.
• Neo liberalism needs inequality and
breeds ill health.
Procedure
1. Community's preferences to decide the
principles underlying health and health
care
2. Different cultural groups – different
principles, different constructs of
health, different barriers to health and
health care and different abilities to
mount the barriers
Martha Nussbaum (1992)
• Risk that we have "impoverished
models of humanity before our leaders'
eyes - numbers and dots, taking the
place of women and men … We want
leaders whose hearts and imagination
acknowledge the humanity in human
beings."
Individualism of Neo Liberalism
• Reducing people to numbers and dots,
or to consumers and customers we
divest them of their humanity and their
dignity; we divest ourselves of our
compassion and we lose the potential
for enriching the lives not just of them,
but of ourselves, and thus, of all of us.
Orhan Pamuk (2001): I
• "At no time in history has the gap
between rich and poor been so wide…
at no time in history have the lives of
the rich been so forcefully brought to
the attention of the poor through
television and Hollywood film… But far
worse, at no other time have the
world's rich and powerful societies
been so clearly right, and
"reasonable"."
Orhan Pamuk (2001): 2
• "Today an ordinary citizen of a poor
undemocratic Muslim country or a civil
servant in a third world country or in a
former socialist republic struggling to make
ends meet, is aware of how insubstantial is
his share of the world's wealth; he knows
that he lives under conditions that are much
harsher and more devastating than those of
a "Westerner" and that he is condemned to a
much shorter life.
Orhan Pamuk (2001): 3
• At the same time however he senses in
a corner of his mind that his poverty is
to some considerable degree the fault
of his own folly and inadequacy, or
those of his father and grandfather. The
Western world is scarcely aware of this
overwhelming feeling of humiliation
that is experienced by most of the
world's population…"
Conclusion
• Maintain diversity of cultures through
diversity of economic systems.
• Neo liberal globalisation destroying diversity,
breeding selfish individualism which in turn
fosters ill-health.
• Promote population health through diversity
of cultures based on diversity of economic
systems, allied to strong social institutions
to promote solidaristic societies.
• Listen to the voices of the community.