David introduced the day with some further comments on why this IPHU course is different from most university public health courses. At its core the difference is between a professional vocation and a political commitment. He cited three cases:
"A woman who is dying in childbirth by bleeding because of inadequate access to proper maternity care"
"Children growing up alone because their parents have died of AIDS"
"A large mining that removes all the minerals and destroys the river"
Health activists in the PHM do not stop at the technical dimensions of health care and prevention. They also worry about the political dynamics and about the kind of political movements which might create a healthier world.
Among the actions that we take to move towards a better world is to work with the communities whose health is damaged or vulnerable because of those wider political factors. The logic of comprehensive primary health care is to work with communities to address the bigger factors, not instead of but as part of addressing the immediate health issues they face.
This course has several elements. One of them is knowledge, including technical knowledge about the health system; health sector reform; the social, the environmental determinants or health; the use of information technology. We also need to learn how to improve our own practice: our political analysis and strategy; how we work with communities and with activists in other sectors. We need to create space in our lives for reflecting together on our practice; learning from each other; learning from our experience.
We need to think about what it means to build PHM in our countries and regions. What are the priorities for building PHM. We can work locally, with countries in Latin America and globally. For example: the challenges of the privatization of water, biopiracy, patents, the use of grains to make energy.
These are issues on which we don't have easy answers. Indeed the answers are going to depend on the specifics of where we stand and when.
One of the elements of this course is the Panel Discussions. Please formulate some questions for these panel discussions; important issues and difficult questions; questions on which many of us may disagree.
Health Sector Reform in Latin America
This topic was led by Eduardo Espinzoa from El Salvador.
See presentation
Los Sistemas de Salud Latinoamericanos son, en su mayoría, mixtos; están segmentados generalmente en tres subsectores: público, seguridad social y privado (lucrativo y no lucrativo). Adicionalmente estos sistemas tienen un alto nivel de fragmentación (proveedores de servicios diversos que operan sin control o integración al sistema)
Nuestros servicios están sometidos a presiones que lo empujan hacia la privatización, esto último está basado en tres premisas:
1- La comercialización de los servicios, que convierte al paciente de “usuario” en “cliente”.
2- Manejo privado de fondos públicos.
3- Invalidación del concepto de salud como un derecho humano básico, esto desresponsabiliza al Estado, al transferir esa responsabilidad al individuo, la familia, la comunidad. Esta última premisa es el sustrato ideológico de la privatización, para justificar y abrir paso a las dos primeras premisas.
La privatización de la salud es el cambio en la lógica del sistema de la producción de salud a la generación de ganancia y acumulación del capital. Esto genera un sistema de salud inequitativo, ya que al imponer en salud las leyes de mercado, se concibe a la misma como un servicio, el cual estará estratificado según la capacidad de pago de la comunidad.
La descentralización transfiere responsabilidades fiscales del gobierno central a las provincias pero no transfiere recursos, por lo que no se logra el objetivo esperado. Además, la falta de una real participación de la comunidad y la ausencia de una invitación a la participación comunitaria en la gestión y administración de los recursos destinados en salud, nos permite cuestionarnos si los que toman las decisiones saben verdaderamente las necesidades de la comunidad.
El resultado del modelo neoliberal es un Sistema Publico colapsado que atiende a la mayoría pobre, los más viejos y enfermos con menos recursos, mientras el sector privado cobra las cuotas de los jóvenes con pocos problemas de salud y acumula recursos y ganancias.
Para que en los sistemas de salud de Latinoamérica haya equidad en el acceso a la salud, nuestra propuesta debe ser abordar el derecho y los determinantes de salud, romper con el paradigma del concepto de salud como ausencia de enfermedad y revitalizar la estrategia de APS.
A su vez debemos recordar que la reforma del sistema de salud que proponemos no está centrada solamente en contrarrestar las privatizaciones que mercantilizan la salud en los servicios o que la limitan al atendimiento en los establecimientos de nuestros sistemas, también combatimos para que la reforma de salud que proponemos enfrente los determinantes sociales de la salud (que están más allá de los servicios) educando y facilitando el empoderamiento de la comunidad para que tome control e incida sobre estos determinantes, de tal manera que sea un proceso social que se construye en la comunidad, con la comunidad y para la comunidad.
Brazilian Health System
This discussion was led by Armando de Negri Filho.
The basic principles of the Brazilian health system are unity, universality, integration and fairness.
Why do inequities persist? He spoke about the mortality rate in childhood by years of study of the mother and by family income quintile.
What is wealth? Is it only the economy, ie the per capita income? Are health policies directed to the right to health of individuals or to the market?
"A democracy without social justice is a mere formality" (Boaventura de Souza Santos).
The struggle for health is not a class struggle, but it is a struggle for democracy by social rights for public health. The politicizing the fight for health arises from key issues such as the tax system. Tax reform to achieve justice is essential. Everything is tax.
We have to fight for causes we believe. We have to take political positions. What gives us strength in this struggle is the struggle for rights. We have to hit what is radically human and socially right. The rights are a system. Understand what rights are.
PRINCIPLES OF HUMAN RIGHTS AND SOCIAL
1. Universal - already is subversive by itself, that is, forces us to think of a way completely. How must we prioritize? But is prioritizing universal? A benefit is not a right.
It is said that we are growing rapidly, that we do not have enough to distribute and we must prioritise. This is neo-liberal logic.
2. UNIVERSALITY WITH COMPLETENESS
There is talk here of care and is not restricted. And all things are full, all the dimensions of the person. Right to focus on services is wide.
From "health doctor" to "care / health care in health." The training of health workers. First is transforming politically and to the extent that the market structure is targeted, the training will follow to meet to meet the market.
What are the obligations of states? The Republican principle is to administer the social right. In Brazil there is a criminalization of protest.
3. SOCIAL PARTICIPATION
The social movements operating within a formal structure, means to have formalized with their own strategies rather than something imposed by the state structure so that, for example, the Councils of Health, are absorbed by the duties imposed.
A new version of policies for poor formulated by the World Bank is coming.
The NGOs working near the World Bank deceived by the participation of civil discourse, but oriented around the principles of neoliberalism. The social movements must make a difference.
How do you calculate an environmental impact, you must also calculate the impact on health.
Funding: How much money is needed for the health system.
A market system prevails. The dynamic that troubles us is that funding is linked to social security. The financing should come from the state.
The attitude of the trade unions to health is a big problem. These unions fought for private plans and not for an improvement in the public system.
The issue of employee health care via private (terceirizações example cooperatives) is a big problem, because it is a way to circumvent the law by hiring.
Social Determinants of Health
Presented by Stela Meneghel
Stela spoke about the work of Latin American epidemiologists (Jaime Breilh, Asa Crstina Laurell, Saul Franco, Sergio Arouca, Emerson Mehra, Tarlov).
She reviewed the work of the Knowledge Networks of the WHO Commission on Social Determinants of Health and reflected on the implications for Latin America of their reports. The knowledge networks included:
(These notes condensed from notes prepared by Eloir Vial.)
Return to the Program Page for Wednesday 10 September
Proceed to Notes Page for Thursday 11 September
Revisit Notes Page for Tuesday 9th September
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