Framework Convention on Global Health (FCGH) – a blog in response to the May 18 Geneva meeting minutes
24/09/2013 Comments Off on Framework Convention on Global Health (FCGH) – a blog in response to the May 18 Geneva meeting minutes
A blog by Marge Berer, Editor Reproductive Health Matters. Originally posted on the blog of JALI – the Joint Action and Learning Initiative on National and Global Responsibilities for Health
I asked JALI if I could write a blog after I had read the minutes of the May 18 meeting in Geneva on the way forward for an FCGH, to raise some issues that I’ve been confronting in the seemingly endless consultations and statements circulating on the internet on the post-2015 world – to do with what an MDG replacement would look like, whether or not universal health coverage as currently conceived is the answer to how to address health, and whether and where my issues of sexual and reproductive health and rights might fit into the “Sustainable Development Goals”, the most likely successor to the MDGs, when they have had such short shrift in the MDGs.
I was particularly struck by the paragraph on the two animating principles of a Framework Convention on Global Health mentioned in the minutes, that is, ‘global health equity (within and between countries) – “global health with justice,” as offered by Larry Gostin – and the right to health… setting clear standards to make it more concrete, measurable, and enforceable… addressing global governance for health… shifting international law towards health. It would ensure for all people the conditions required for health, including health care, public health, and social determinants of health, setting standards and establishing a national and global financing framework to enable universal access to and coverage of health care and public health measures (e.g., clean water, sufficient nutritious food)… directly address domestic inequities…[and] promoting Health in All Policies.’ (pp.2-3)
Just as people in the meeting raised the fact that some participants in the FCGH process required more explicit attention, e.g. health workers and health worker unions, as did some issues, e.g. mental health, I would like to raise three aspects that I think need to be part of the FCGH discussions:
i. Gender issues – that is, the differences between men and women in their health needs, their access to health and health care, and the inequities in that differential access. Gender issues in relation to health are crucial to any convention. There has been a lot of work by women’s health advocates on gender issues in relation to women’s health but far less work by either men or women on gender issues in relation to men’s health. In the same ways as girls’ and women’s health issues were at one time almost invisible in the previous century, attention to boys’ and men’s health issues has not been developed in the past 30 years, in spite of the growing attention to women’s health issues and wide-ranging work on gender, both in academia, by the women’s health movement and even in WHO. In a recent paper I was considering for publication, for example, it was said that gender-based violence against women was the most common form of violence, when in fact men experience far more violence globally overall, but between each other, whereas women experience violence mostly from men. Thus, work is needed on how to address gender issues within an FCGH in relation to the right to health, the social determinants of health, health financing, etc, and how this might be approached needs much more thought and consideration.
ii. Religious, political and “cultural” opposition to what an FCGH would stand for, being used most vocally today to justify why access to crucial aspects of health and health care related to sexuality and reproduction are being withheld and denied, and many sexual and reproductive rights condemned and criminalised. Underlying this opposition are two forms of hate: misogyny and hatred of any form of sexuality that is not heterosexual and heteronormative.
One of the reasons I support a Convention is that it would give greater weight to all these issues by requiring not only non-discrimination and equality, but also regular examination, analysis and critique of country programmes, along with official recommendations for policy and programmes, and demands for accountability and action through interpretation of the implementation of the convention. We are beginning to see such a framework making a difference in relation to sexual and reproductive rights issues, particularly via the work of CEDAW. So I recommend studying CEDAW’s history, functions, and procedures particularly and how they might be applied more broadly across health. I would be interested in being involved in this in the future.
iii. The process of developing the successor to the MDGs may cut out the few specific aspects of health and health care that were allowed into MDG 5, where they were mostly reduced to their lowest common denominator and stripped of their complexity, e.g. universal access to reproductive health was a late add-in to MDG 5, which never moved beyond superficial attention to a few aspects of reducing maternal mortality, diluted heavily by tacking newborns, infants and children onto “maternal” health, and omitting the great majority of interlinked sexual and reproductive health problems.
Universal health coverage in my opinion may also succeed in shortcutting and eliminating the “controversial issues” in whatever is included under a “unified health goal” post-2015, and it may also make support for addressing specific aspects of health equally or even more difficult. Having devoted two recent issues of Reproductive Health Matters to privatisation in sexual and reproductive health services, where articles provided evidence of a resulting increase in inequity of access to health care among the 4th and 5th socioeconomic quintiles of many African and Asian countries, I am worried that the health goal that is eventually agreed is likely to be biased one way or another towards consumerism, commercialisation and privatisation of health and health services, and their financial underpinnings such as health insurance. I am very uncertain of the value of what has emerged so far as regards universal coverage from WHO, given the pressure on the agency from the World Bank, big pharma, world trade policies, and the influence of private/foundation donors, when measured against what we would like to see as the basis for the Framework Convention on Global Health.
13/07/2012 Comments Off on Making change happen is in the air
Editor, Reproductive Health Matters
Below, are excerpts from my editorial in RHM 20(39) May 2012. This issue is about reducing maternal mortality, but the more I reflected on it the more I realised it had implications for this week’s summit on family planning.
Making change happen is in the air, from the UN Secretary-General down to the most remote village… Yet, in certain ways, the world is moving backwards when it comes to dealing with women and pregnancy. Simone Diniz calls it a return to “materno-infantilism” – treating pregnant women like children who need looking after… Today, in much of the literature, all pregnant women are called “mothers” whether they’ve ever had a baby or not. Yet pregnancy has more than one outcome and is not only about women who “deliver”. It’s also about women who experience miscarriages, stillbirths, infant deaths, lack of access to contraception, unwanted pregnancies, unsafe abortions, and lifelong obstetric, reproductive and sexual morbidity. Yet these are nearly invisible in PMNCH these days, and safe abortion – an integral part of women’s right to decide the number and spacing of their children – may be made invisible in the new Family Planning Initiative as well…
The papers [in this journal issue] show that some countries are making serious efforts at strengthening and improving their health systems in relation to reproductive health care and maternity services. Based on data that show who is dying and why, they are making policy and programme changes, such as low-cost delivery services for poor and migrant women, opening new obstetric emergency care and referral centres in hospitals, training more health professionals, and providing health education for women, as in Shanghai (Du et al)…
Others are strengthening the whole public health system, especially in rural areas where most poor women live, ensuring better leadership and governance, increasing health workforce skills, supporting community-based health insurance, and increasing contraceptive services, as in Rwanda (Bucagu et al). They’re promoting peace, stability, economic growth, poverty reduction, improved primary education, better roads and communications, access to information on health and health services, and making health care free of cost for the poor, as in Cambodia (Liljestrand & Sambath)…
In contrast, in some countries, appalling, chaotic, uneven, negligent and abusive situations persist. Among the 22 million women each year who have unsafe abortions, adolescents suffer the most from complications and have the highest unmet need for contraception (Shah & Åhman). Custom, lack of perceived need, distance, lack of transport, lack of permission from husbands, cost, unwillingness to see a male doctor are still preventing women from seeking antenatal and delivery care, e.g. in northern Nigeria (Doctor et al), but in many places, these services barely exist anyway…
In the poorest of countries, women may have more pressing health needs even than for maternity care, e.g. in Haiti, where women identified access to any affordable health care, potable water, enough food to eat, any employment, sanitation and education as their most crucial problems (Peragallo Urrutia et al)…
Even more broadly, lack of national commitment has been identified as critical in 33 sub-Saharan African countries, as well as very low levels of public financing for health and health services (let alone maternity services), poor coordination between key stakeholders and partners, poorly functioning health systems with poor logistics for supply, distribution and management of essential medicines, family planning commodities, and equipment, and a chronic shortage of skilled health professionals (Ekechi et al).
In several South Asian countries, cash is being given to pregnant women to deliver in facilities, but some studies are finding, e.g. in India, that when women arrive, there is limited or no antenatal care, no birth attendants with midwifery skills, no emergency obstetric care in obvious cases of need, and referrals that never result in treatment (Subha Sri et al). And now, these same women have a sense of entitlement, and they are protesting.
Several governments in Latin America may be embarrassed to learn that their levels of budget transparency in spending on specific aspects of maternity care were found to be very low, and that they need better budgeting modalities, better health information systems and guidelines on how they might better capture data on expenditure, in order to track and plan local and national progress (Malajovich et al). Similarly, an assessment of cash transfer and voucher schemes designed to stimulate demand for services and reduce cost barriers to maternity care found increased use of maternity services in several south Asian countries, but also a need for more efficient operational management, financial transparency, plans for sustainability, evidence of equity and, above all, proven impact on quality of care and maternal mortality and morbidity (Jehan et al).
The papers [in this journal issue] describe a range of models for advocacy and taking action to expose violations of human rights, poor public health practices, absence of monitoring and regulation, failure to ensure national accountability for sexual and reproductive rights and to provide remedies and redress in the event of violations (Kismödi et al).
02/06/2011 Comments Off on Privatising the NHS can bring down a government
LETTER TO MPs, SENT 28th MAY 2011 – INTERNATIONAL DAY OF ACTION FOR WOMEN’S HEALTH
I am writing to urge you to call on the Prime Minister and the Secretary of State for Health to withdraw the NHS Bill, as recommended by the British Medical Association and many others with expertise in health care and health systems. This Bill is the wrong response at the wrong time. It is far too complicated, with potentially costly and negative consequences, to be amended piecemeal.
Everyone recognises that the cost of health care is a major issue, particularly with an ageing population. However, this Bill does not address the costs of an ageing population. Indeed, it says nothing about it.
Instead, it removes the responsibility for health care from the Government altogether. It does this by handing over the responsibility to a body independent of Government, called Monitor. It shuts down the only remaining Government bodies responsible at regional and local level (Strategic Health Authorities and Primary Care Trusts) for managing health care spending and ensuring national standards are met. It places their role in the hands of GPs, who will be forced to create the equivalent of these same bodies, but not in the public sector. And it requires all hospitals to become independent trusts, thereby forcing them to take independent responsibility for balancing their books and leaving them on their own to sink or swim.
Lansley’s Bill also takes away most of the powers of NICE, a body whose contribution to standard-setting and control of costs, such as drug costs (crucial with an ageing population), based on public health expertise and scientific and clinical evidence, has been absolutely essential. This will be a fatal blow to control of spending on drugs and quality of care.
All of this is privatisation of the NHS. The upshot will be fragmentation from within – the postcode lottery instituted as the basis of policy, dressed in deceptive language about “choice” and “local control”.
You will say perhaps that the last Labour government started this process, as if that were justification enough to go so much further. It is not. The Thatcher and Major governments “started it” and Labour certainly took it further, no one disputes this. Under their jurisdiction, since 1990, an internal market was created in the NHS, which led to massive growth in managerial spending. Whole sections of the NHS were moved out of the public sector – GPs became independent; so too did dentistry, optometry, ambulance services in many places, and much more. Private medicine also grew, e.g. for cosmetic surgery. And private companies came in, offering Strategic Health Authorities and Primary Care Trusts their services (for a profit) in a myriad ways, such as handling hospital appointments and sending reminders to come for screening. Moreover, through private finance initiatives, many hospitals were committed to taking out and paying back expensive private loans to support badly needed modernisation, as the whole system was falling behind, precisely because it had been starved of funds prior to 1997.
What Labour did right was to inject the funds and push modernisation. It set standards of care and targets to ensure those standards were reached. And the reason why the Labour government was able to make so many needed improvements was because the system as a whole was still under the control of the very public bodies that the Lansley Bill will close down – the Ministry and Department of Health, Strategic Health Authorities and Primary Care Trusts.
So, yes, previous Governments started it. Some of what they did turned out to have been a very good thing, but not all of it. Not all by far. The internal market is the main reason why bureaucracy has grown so much, and it and private finance initiatives have increased costs greatly. The question is, does the Lansley Bill address the real problems? Unfortunately, it does not. It is likely to exacerbate them.
Privatisation takes many forms. Lansley’s Bill does it first and foremost by moving all the remaining parts of the NHS in the public sector out of the public sector. At the same time, it opens the door even wider to private health companies and service providers. How? Under European trade regulations, the bulk of the NHS will be independent of government, so it will be required to allow competitive tendering – from which only the public sector is exempt. Thus, the replacements for Primary Care Trusts (set up by GPs), GPs themselves and all foundation trust hospitals will have to open themselves to competition – privatising the NHS in all but name.
It is a false assurance by the Secretary of State that competition will not be permitted. If he does not know this, his competence must be questioned, and if he does know it, then he is trying to pull the wool over our eyes.
The Conservative Party supports privatisation of public services. It would therefore be disingenuous of Conservative MPs to pretend that, unlike all the other reforms they are pushing through at breakneck speed, the Lansley Bill does not aim to privatise the NHS, and radically.
Labour and the Liberal Democrats have tried to have it both ways for too long It would be disingenuous to think that mere amendments could remove the profound effects this Bill will have. The time has come for both parties to take a stand against privatisation of public services. Together, you have the power to force the withdrawal of Lansley’s Bill. The fact is – as has been shown in country after country – that the public will soon be paying user fees for health care in one form or another as a result of these reforms, as we already do for dentistry. The poor, the disabled and the elderly will be especially hard hit.
Every medical professional body and health trade union has expressed opposition to and/or grave concerns about this Bill. The public do not fully understand how this Bill privatises the NHS, but they have taken on board the message that it does. Week after week on Question Time they have shown it. Some 420,000 voters have signed the 38 Degrees petition against the Bill as I write. That’s a lot of votes.
“Protecting the NHS” is a vote winner, yes. But privatising it can also bring down a Government.
15/03/2011 Comments Off on Privatisation: changing the ethos of health care delivery
RHM is about promoting sexual and reproductive health and rights globally, but sometimes it’s important to focus on what’s happening at home.
First, though, I need to acknowledge the heartbreaking devastation in Japan and say that this shouldn’t be seen as an isolated natural disaster. It (and the floods in Australia and the tsunami in Thailand before that, among others) is just the beginning of the global environmental disaster we are continually being warned about. If we don’t take heed soon, our children and grandchildren will inherit a far more frightening world to live in than we can imagine now.
And now, to the news in the UK, where a movement is growing both among health professionals and at the grassroots to stop passage of a Government bill that would dismantle and privatise our National Health Service in England. Today, at 11:45am, a special session of the British Medical Association voted “overwhelmingly” to call on the Government to withdraw the bill in its entirety. This is a major victory in an ongoing struggle to stop the privatisation of health care in the UK, which has been going on since 1992 under the last Conservative government, and which this bill would have finalised under the coalition Government in office since last May.
Privatisation means many things. First, it means changing the ethos of health care delivery from being for patients into being for consumers. Some years back, we thought it would be good to stop using the word “patient” for people such as those seeking contraception, who weren’t ill. However, the term everyone has substituted, “client”, is applied across the board and ignores the fact that most health service users are ill and may have a life-threatening condition, such as obstetric complications or breast cancer, or chronic problems, such as fistula or infertility.
A paper RHM will be publishing in May looks at why maternal morbidity is higher among immigrant women in the Netherlands than among native Dutch women. In it, the authors talk about a consumer-centred care model that is being promoted by the Dutch government, which sounds similar to what the UK government is promoting as well with their bill. They claim on both sides of the North Sea that the aim is to improve the quality of care by giving people more “choices” over the care they receive. But as this paper observes, women with a life-threatening condition such as pre-eclampsia need competent diagnosis and decisive action by health professionals – not a “choice” of where to get that help or patient-centred participation in the decision of what kind of help it is, in the consumer sense.
This distortion of the concept of “choice”, at least over here, is about turning health care provision more and more into a marketplace, where publicly funded GPs, primary care and specialist services such as mental health services, and hospitals as well, must all become independent bodies and compete with each other as regards which services they provide, what they charge for them, and also for referral of patients to them. That’s privatised medicine, I don’t care how you dress it up.
Under European Union-wide policy, if a service is not almost wholly provided by the state, as the health service in the UK here currently still is, then the rules of competition that apply to free trade would also apply to health care provision. This could potentially bankrupt publicly-funded hospitals and services. Anyone – whether a public or private health care provider – would be allowed to compete for patients and undercut each other in their efforts to do so. This is called allowing in “any willing provider” in the language of the current Government bill. Its effect would be to destroy the ethos of cooperation in the health system.
It is incredibly heartening to see so many health professionals in this country rejecting privatisation, since many of them could benefit enormously at a personal level by “going private”. The UK was recently found in a survey to be one of the most equitable health systems in the developed world. The USA, in contrast, was among the worst.
Why should we be trying to emulate and copy a model that is among the worst of its kind? Because large, private profit-making health corporations in both the USA and Europe-wide are fiercely lobbying our politicians to “let them in” and word has it that they have close contacts inside our Department of Health and give a lot of money to the campaigns of politicians in more than one of our main political parties who will support their invasion of our much-loved, publicly-funded, publicly provided NHS.
Does it need improving? Oh yes! Constantly. Is privatisation the way forward? Definitely, resoundingly not.
And now, I need to get back to editing the next journal, which has more articles on privatisation and commercialisation of sexual and reproductive health services.