Hans-Ulrich Deppe, MD
Professor for Medical Sociology and Social Medicine
J.W. Goethe-University of Frankfurt/ Germany
X Congreso Latinoamerikano de Medicina Social, IV Congresso Brasileiro de Ciencias Sociais e Humanas em Saude, XI Congress of the International Assotiarion of Health Policy , Equidade, Etica e Direito a Saude: Desafios a Saude Coletiva na Mundializacao vom 12. bis 18. Juli 2007 in Savador de Bahia/ Brasilien
To speak about UHCS on the periphery of capitalism in this general form is not easy. The countries on the periphery of capitalism are different. I want to outline some questions and problems with thesis.
1. Health care systems in general are always determined by the structure and development of a country.Health care systems are not isolated social constructions. They are rooted deeply in the structure, the culture and the history of their societies. They are embedded in a society. They are often one pre-condition for social peace inside contradictory societies. In opposite to the increasing globalisation of capital health care systems are strongly connected with the national states. The transformation of health care systems implies more than mere technological changes. The structural change of health care systems is always the result of social and political struggles. Often it is the result of the social compromise between capital and labour – especially in times of social and political crises. This means that a special health care system has to be fought for. In the history in many parts of the world health care systems changed structurally after revolutions and wars, after the defeat of fascist and military dictatorships or after the collapse of the socialist countries. And the struggle for a health care system is not a single action but it is a permanent fight. A health care system is the mirror of a society. It reflects its history and its character. Because of that every country needs to develop its own health care system.
An empirical example fort this is the difficult current process in the European Union which follows the formula: Economic/currency union – political union – social union.
2. Before we go on it makes sense to explain what I understand under universal health care systems.
Universal health care is characteristic for a health care system in which all residents of a country have access to health care, regardless of medical condition. Medicine in UHCS is orientated to the need – to that what is medically necessary. The majority of universal health systems are funded primarily by tax revenues (like in Denmark, Sweden or Canada.) If universal health care systems are funded primarily by taxes we have to look exactly how the national tax policy is structured and who will be favoured or discriminated by it. We have to look if it is based on solidarity or if it supports social privileges. Other nations (like Germany, France or Japan) have a universal health care system in which health care is funded by private and public contributions. Universal health care systems vary in what services are covered completely, covered partially, or not covered at all.
3. UHCS on the periphery of capitalism have different histories:
– Some have a colonial heritage. Until today some of them have relevant elements of their former colonial power. As examples we can mention South Africa or states in India.
– Others are the result of a revolutionary process. It is interesting to see that health and education are main aims in revolutionary movements. The most important country in this sense is Cuba with its famous health care system. It was the model for many other health care systems.
– And some UHCS are the result of the struggle for democracy against military dictatorships. Here I think at Brazil and other Latin-American countries. Today in Brazilhealth as a social right is enacted in the constitution. And the state is obliged to guarantee a general access to health care.
These different origins of UHCS help to understand how strong the people identify themselves with their health care system and how strong it is rooted in the consciousness and culture of the population.
4. In general we can say that in the countries on the periphery of capitalism the class character of health care is more developed than in rich capitalist states – even if they have UHCS or not. UHCS in the most countries on the periphery of capitalism offer health care to the lower social classes. Often they have serious deficits in the supply of benefits and their quality. Sometimes they exclude relevant parts of the population such from the informal sector and urban areas. There is not enough money for health care – especially in economic or financial crises. But the distribution of money for social matters is a political decision. Other political activities have obviously priority. The budget is strongly limited. Some times tax raising is ineffective. Or corruption and lack of control are a hindrance.
In many countries parallel with the UHCS is a broad private sector. It is an increasing sector supported by the governments with laws and taxes – and taxes mean collective money. Often the working class pays more taxes than the dominating class. In the private sector the medical institutions have a high technological level. It is used mainly by the upper classes – but meanwhile also by the middle classes.
5. At this time almost all countries are confronted with the processes of globalisation, deregulation and privatisation. And inside the countries the public sector – especially universal health care – is heavily confronted with these developments. Structural adjustment programs, with their social austerity policies, have done a lot of damage to the infrastructure of health services in countries on the periphery of capitalism.
Globalisation – the international expansion of capital accumulation – is an amorphous concept. Some authors speak from a new imperialism. During the last two decades worldwide the process of capital accumulation got a relevant push by the collapse of the socialist states and the development of the productive forces, triggered off by the micro-electronic technology. Most aggressive in the process of globalisation is thefinancial capital – supported by the global money institutions like the World Bank, the International Monetary Fund and the World Trade Organisation. This sector meanwhile dictates how other sectors of the society shall be structured and what they have to do. Fore that they use as instruments financial credits with special conditions. And these conditions are mainly combined with the obligation to privatise public property in the social sector. Market and competition shall regulate more social relations. The thinking in categories of business management penetrates and subsumes all social niches. And – as we know – the first aim of business management is always to make profit. As one result we can register a worldwide rise of instability, uncertainty and social polarisation – not only between the rich and the developing countries but also inside the countries. The social question is marginalized on the political agenda and becomes irresponsibly neglected. Poverty increased in many parts of the world.
6. In general UHCS on the periphery of capitalism are public institutions. They are paid by the governments. And the governments need money. As a result of a weak and complicated economic development and a special tax policy they are in a chronic financial deficit. Most of them are dependent from financial credits. Insofar the World Bank and the IMF had and have a light game to force through their strategic aims. And that means especially for the UHCS a pressure in the direction of privatisation. One example for this is the privatisation of public hospitals. It was a general tendency in many Latin-American countries. Not only in the hospital sector but also in other sectors of health care we can see this tendency: inTurkey last year the IMF gave a credit to the government (10 Billion US$) with the obligation to privatise its 1600 public policlinics and to privatise the public retirement insurance. In Argentine the privatisation of the public retirement insurance was too a demand of the IMF combined with a credit.
Meanwhile we can say: The main idea that privatisation leads to lower costs and better quality of health care was empirically wrong. It sourced out solely costs from the public sector. Privatisation made more difficult the access to health care. It lead to greater inequalities in health service utilisation and opened the door for more inequity and discriminations. One country on the periphery of capitalism where neo-liberalism got an extraordinary strong impact is South Africa. It has an extremely high Gini-Coefficient. Here it is especially relevant because South Africa is the country with the highest rates of HIV infected residents. And that is not only a cultural question.
Even if they want, the states on the periphery of capitalism have not so much power to resist the international money organisations like rich capitalist countries with welfare states p. E. in western Europe. But in these countries too we can register the strong pressure of neo-liberalism on the UHCS. This strategy of the World Bank and the IMF increased poverty and social inequality. In some countries on the periphery of capitalism the retreat of the state – which is a neo-liberal demand for 10 to 15 years – affects meanwhile the economic productivity and the process of capital accumulation. The expected results of economic growth were for a long time weak. The rate of unemployment remained on a high level and poverty is going on. The de-stabilisation of social structures is a disaster for the people living in such countries. This empirical experience meanwhile is becoming aware for some experts in international organisations. And national governments especially in Latin-America think about the relevance of state intervention and state regulation. The preferred sectors are health care and education. Meanwhile it is possible to discuss a sustainable and social equal financing of public health care by the state. The neo-liberal dominance of the market becomes slowly but more and more supplemented by policy This is a sad empirical example therefore what happens when powerful global and national institutions fail with their concepts and strategies. Now some authors speak from a break or the beginning end of the neo-liberal hegemony. But others are sceptical and speak from the “reorganisation of the bourgeois hegemony”. I will not elaborate these different positions here and now.
The basis for this change in the consciousness of national elites in countries on the periphery of capitalism were – beside the economic disappointment with the neo-liberal regime – increasing social conflicts, which appeared in organised forms as social movements, but also in the form of criminality and violence in the cities. Social mass-movements with anti-neo-liberal orientation revived and got their force from the concrete deficits of the neo-liberal regime. In this context we have to mention among others.
– the Zapatist movement in Chiapas in Mexico;
– the movement of the Piqueteros in Argentine against unemployment,
– further the movement of landless people in Brazil,
– the local rebellion in Arequipa in Peru against the privatisation of the electric power station (2002),
– the referendum against the privatisation of water in Uruguay (2004),
– the protests and strikes in Bolivia against the privatisation of water and natural gas. – And last but not at least the broad movement in El Salvador against the privatisation of the public health care system (2002) which was also a condition of a credit from the IMF.
Over this we have worldwide international mass-movements like the Social Forum, the Peoples Health movement or in Europe attac which are mobilising against the privatisation of basic social needs.
In the most countries these mobilisations remained more marginal and temporary. Until now it did not lead effectively to a fundamental correction of the neo-liberal course in the mentioned countries. The main question is if it is possible to point out the real origins and causes, the centres of the power and if it is possible to create a real power against this.
8. What is my message on the basis of or empirical and theoretical researches?
This set of problems draws the conclusion that a society must have protected sectors which are oriented towards the common welfare and cannot be entrusted to the blind power of the market and the deregulating strength of competition. I am deeply convinced that we have relevant sectors in our societies which should not be privatised and commercialised, because it will counteract and destroy the humane and social values of our societies. We have to respect and to keep on areas in our societies, in which the communication and co-operation is not commercialised, where services have not the character of a commodity. Such protected sectors refer to the way vulnerable groups are dealt with (children, elderly, psychiatric patients etc.), to vulnerable social goals such as solidarity and equity, or to vulnerablecommunication structures –especially such which are based on confidence like the physician-patient-relationship. Indeed, these protected social sectors form the basis of a human social model which should be a fundament of a UHCS. This quality – to have protected sectors – needs to be accepted. It must achieve again the hegemony in the civil society. The quantity, the magnitude and the extent of such a welfare-oriented safety net, is dependent on the existing strengths of political organisations and social mass-movements which articulate the mood in the populations. The fields of illness and health are by no means peripheral or marginal societal phenomena. In fact, the right to health is a human right. Therefore the UN proclaimed their program “Health for all” in the seventies of the last century in Alma Ata. Occasionally, the shameless instrumentalisation of basic social values for disguised private interests leads to the false assumption, that the meaning of human rights lies in their abuse.
But I think human rights are not to be commercialized; they don’t lend themselves to be marketed, without destroying their meaning. And that means for health in general – formulated as a political parole and also basic scientific knowledge: Health is no commodity! Health is not for sale!
Boris, St. Schmalz, A. Tittor (Hrsg.), Lateinamerika: Verfall neoliberaler Hegemonie? Hamburg 2005, besonders S.40-68 und 270-282.
Giovanella, M. Firpo de Souza Porto, Gesundheitswesen und Gesundheitspolitik in Brasilien, Arbeitspapiere aus dem Institut für Medizinische Soziologie, Nr. 25, 2004
Ch. Holden, Privatization and trade in health services: A review of the evidence, in: IJHS, Vol. 35, Bd. 4, S. 675-689, besonders S. 681 ff.