Politics – power – health: the topics of this year’s Armut&Gesundheit (Poverty&Health) Congress are tough ones. Their interrelation also explains why the wonderful promise of health-for-all is still to be fulfilled. The goal that inspired the foundation of the World Health Organisation (WHO), is not failing to be achieved because of lack of resources or knowledge, but solely because of policies serving powerful interests which have nothing to do with promoting health for all.
Politics can make people ill, as well healthy, and the direction in which the pendulum swings depends on prevailing power relations. While this is scandalous, it is also encouraging. If politics are responsible for the precarious state of world health, then politics have also the power to change this situation.
I would like to talk about a concept which may contribute to this change. This is the idea of “Cosmopolitan Health Insurance Scheme” which ensures that everybody everywhere in the world has access to proper health care services.
Naturally, universal access to basic health services is not enough to solve all the problems of world health, but it is an important lever. Like income, education and nutrition, access to functioning social protection systems is one of the social determinants of health. Health care services are important, because even under ideal social circumstances people fall ill or suffer accidents, or need assistance at birth or in old age. The problem is not curative services, but the way in which these are perceived and organised in society. There is a major difference between depending on charitable services, as is the case in many parts of the southern hemisphere, and having a legal right to social protection.
Compared to people in the South, those living in the northern hemisphere still enjoy good health services, although there is plenty of room for improvement. But this is something I don’t need to tell you! Yes, in Germany there is statutory health insurance, but not everyone belongs to it, and everyone does not receive the same services. Public servants have their own insurance scheme, and upper income groups can take out private insurance. Undocumented individuals are dependent on informal services. And the rest of the population are the target of competing health insurance schemes, which not only takes the principle of solidarity to absurd lengths but also adversely affects the services themselves. People who are worse off and chronically ill suffer particularly from competition between insurance schemes, which follow economic pressures by giving preference to healthy patients as customers.
But the scandal runs deeper: hardly anyone still argues that our prosperity – and our health – is based on exploitation of the people in the South. Even conservative politicians like the current Minister for Development Gerd Müller are arguing that we cannot continue to live at the expense of others. But be careful! - a call such as this can rapidly end as a call to tighten our belts in order to legitimise the dismantling of social services in our own countries. We are also experiencing the effects of the radical market-oriented reorganisation of the world in this country. Pressure on the providers of health services is also increasing here.
This is not a sensible system. Its beneficiaries are those who would ideally like to abolish public health services entirely. Their reasoning, according to Deutsche Bank’s analysts (for example), is that health is a booming market which promises rich returns, as the Bank’s investment recommendations bluntly put it. And the mistaken tax policy means that there is plenty of investment capital looking for a home. Privatisation of health care is rapidly advancing worldwide. Private hospital operators, such as the European leader Helios Fresenius AG, are already planning their own insurance systems. If the trend continues, in future we will only be able to go to doctors who are employees of a profit-oriented insurance company.
Under these circumstances, and no matter how harmless it originally seemed, the idea of publicly-controlled universal insurance becomes a provocation. Thinking it through, however, we find it represents not only a way out of many of the existing business models, but an actual opportunity to create an equitable global society.
And this is where the little adjective “cosmopolitan” comes into play. There are at least two reasons why I feel it is necessary to extend the idea of universal insurance to the global level.
Public services which are guaranteed without regard to national borders are the only way to meet the universal human right to health, and also the only way to preserve and develop the European social systems in the long term. If we stick with national approaches, the reduction in social services and the dismantling of the social safety net that we are witnessing today will be even more noticeable than in the past, including in this country.
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This is because health has long since passed the point of being a national concern. The hope that we can create a social policy paradise in our own country without worrying about the rest of the world, is vain in the face of Germany’s integration in a global reality that is marked by crisis. Domestic policies alone are not sufficient to influence the consequences on health caused by either global climate change or transnationally active capital. Nation states have had their day, and are in a precarious condition. Instead of tackling the crucial global issues, they are stuck in their national concerns. Politics is primarily concerned with securing economic locational advantages, in order to reward its voters with a few benefits, if all goes well. However, all this just makes the global crisis worse, and we have long seen this reflected in the state of world health.
The enormous progress that medical science a has made in recent decades has bypassed large parts of the world’s population. These still suffer – and more than ever so – from miserable life conditions which prevent them from achieving their full health potential.
Like climate change, which is having increasing social impacts worldwide, and the growing spread of violence, the crisis in world health is not an accidental occurrence. It is the result of politics which has placed the interests of commerce and administrative power above human needs and legitimate claims.
Although the world has grown together in the course of globalisation, it has not become the “global village” that was occasionally spoken of. The emphasis was not on creating relationships between global citizens but on global expansion of an economic system based on growth and profit. And this has now reached the furthest corners of the Earth. The gap between rich and poor – and with it the inequality in health – has widened rather than narrowed. The neoliberal promise that liberalisation of transfers of goods and capital would also benefit the poor has proved deceptive. Instead of a “trickle down” effect, we have seen the opposite, a redistribution from those at the bottom to those at the top. As the English saying so accurately puts it, “take from the needy, give to the greedy”.
It makes more of a difference than ever whether we are born in one of the flourishing regions of the “Global North” or in the “Global South”. In this context the terms “North” and “South” go beyond the geographical location and include the political environment. Indeed, there are now zones of exclusion in the suburbs of North America and Europe, while, conversely, prosperous islands of wealth have formed in Africa, Asia and Latin America.
Present-day deep social divisions are also reflected in access to health. Whereas abundance prevails in some areas, 870 million people worldwide are suffering from malnutrition, and the trend is rising again. Four billion people lack adequate sanitary facilities. Two billion have no access to essential medications. Some 90% of world-wide health spending is accounted for by the 20 richest nations, which in turn are home to only 20% of the world’s population. And while research is proceeding under high pressure to identify expensive individualised therapies, 25 million people a year still die in the South from diseases which could be easily treated.
Today, only a global élite is benefiting from the possibility of accessing health resources from all over the world. They employ nurses from the Philippines, import dentures from China, travel to the USA for heart surgery or to India for Ayurveda retreats, and increasingly demand lifestyle drugs which include preparations for obesity and hair loss.
Health inequality is no longer a just problem limited to the southern hemisphere. The poverty gap is also increasing in Europe, with hospitals facing closure for financial reasons. In Greece recently, lack of funds has repeatedly forced cancellation of even lifesaving operations. In Germany, according to a 2015 study by the Robert Koch Institute, high-income individuals live on average ten years longer than people with low incomes. In Glasgow, the difference in life expectation between children from poorer city districts and those from wealthy areas was even 28 years.
The global unleashing of capitalism has led to a dramatic increase in social inequality, both between and within countries. The situation is so precarious that even the Davos World Economic Forum, the annual gathering of the movers and shakers of the radical market-oriented reorganisation of the world, had to admit that social insecurity, the leading risk facing the world, can only be countered by a correction to free market capitalism. According to German sociologist Heinz Bude “In terms of global society, the mega-theme for the next 30 years is no longer ecology and no longer sustainable development, but inequality,” and I fear that he is right.
And yet the world is literally swimming in money. Individual wretchedness contrasts with astronomically inflated private wealth. There is no lack of resources to ensure adequate and healthy food for all. With the available agricultural production capacity we could feed 12 billion people, almost twice the current world population. Despite this, a child dies of starvation every five seconds. As the Swiss sociologist Jean Ziegler says, forcefully but accurately, they are being “murdered” by circumstances.
Let’s look at Africa. In hardly any country there can the population access appropriate services from public health facilities. Where these do exist, they have often been rendered unrecognisable in the course of economic structural adjustment programmes imposed on the countries at the time of their integration into the world market. To date, scarcely any country in Africa has recovered from the required cuts in social policies. When the Ebola epidemic broke out in west Africa in 2014, the few remaining health facilities were more likely to transmit the disease than to help. They were simply too poorly equipped and hopelessly understaffed. Because there are no jobs for them, more Sierra Leone doctors work in OECD countries today than in Sierra Leone itself.
Where public health services are poorly trained or entirely lacking, people are dependent on private services. Frequently, they have to sell their last possessions to pay for the necessary health services out of their own pocket. Such “out of pocket” payments, as the WHO calls them, exclude those people from appropriate health care who most need it: the poor and destitute.
Private payments are no problem for the wealthy, but can lead to disaster for the rest. “Out of pocket” payments stop people from getting medical help in time, and result in treatment being prematurely ended for lack of money (which has accelerated the spread of resistance). Far too often, they drive people into complete ruin. Every year, 100 million people fall into poverty because they have to pay privately for necessary health care.
The fact that such misery ultimately returns a profit demonstrates the two-faced nature of unchained global capitalism. More and more often, people are forced to take out microcredits to pay doctors’ bills. Microcredits stand the principle of mutual assurance on its head. Access to medical care is then not only conditional on an individual’s ability to pay but further burdens them with interest payments. The final result is a life of permanent indebtedness.
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Protection and enforcement of human rights are public functions which cannot (or only to a limited extent) be delegated to commercial actors. Because illness leads to poverty and poverty leads to illness, it is social-policy folly to tie access to basic services to the purchasing power of their users.
And yet this is what has been done worldwide through the privatisation of public institutions. More and more often, legal rights embedded in social legislation are being replaced by ability-to-pay as the criterion for access to health, education or culture. The concept of solidarity has given way to a neoliberally exaggerated concept of absolute individual responsibility: “if everyone thinks of themselves, then everyone is thought of” is the cynical creed of that Neoliberalism which has accompanied the radical market-oriented reorganisation of the world.
We are slowly beginning to realise the dubious consequences of this policy, which are apparent for example in the global increase in distributional conflicts, growing violence and – obvious to all – the millions of refugees and migrants. In principle there are only two ways to counter these multiple crises. Either we achieve social equity, or the privileged regions of the world continue to seal themselves off.
The current approach of the global North is to seal itself off. It is revealing that health policy today is speaking less and less of universal rights and more of “health security”. Rather than trying to counter the causes of ills, this is concerned with how to bring the crises resulting from misplaced policies under control, so that they no longer disturb. The goal is not to bring about change, but rather to preserve the status quo. If we look at the agenda of the security policy-makers, we look in vain for the prevailing economic relationships with all their negative effects on people’s circumstances, and find instead the question of how to superficially counter the consequences of a radical market-oriented policy – growing population pressure, migration, slumification of cities, epidemics – which are obviously seen as inevitable.
Faced by a world which is coming apart, the need for security is entirely understandable. In times of growing uncertainty, who would not prefer greater security? The question is then, whose security is involved, and what should be secured.
The focus in “health security” is on efforts to prevent the spread of diseases. The goal is not preventive avoidance of crises, but the most efficient crisis management possible. This is also apparent in the “International Health Regulations” which have been negotiated and adopted within the framework of the WHO. Their central concern is that the global movement of goods and services, labour and tourism should not be endangered by pandemics. Much in the health security concept recalls colonial-era medical policy on epidemics – believed to be a thing of the distant past – which tried to protect the residential districts of the colonial rulers from the compounds of the natives with a “cordon sanitaire”.
It is actually not so long ago that concern for health belonged to the duties of local police in Europe as well. In Prussian Germany, for example, the stated goal of public health care was not the wellbeing of the individual, but ensuring the ability to work and the productivity of the population as a whole. Later, this was joined by ensuring fitness for military service, and finally the insane idea of NS eugenics or racial hygiene.
The emphasis on security threatens to blind us to what should be the real and proper aim of policy – human rights. In contrast to the human rights, concern for security is not based on the principle of universality. Anyone talking about security has their own security in mind, first and foremost – a security tied to certain territory or privileges. Any perceived threat to this situation is always subjectively shaded.
Security policy strategies are seldom aimed at those who most need social protection – the poor and destitute – and are usually concerned with security for the possessions of the better-off. More accurately, with protecting the lifestyle of those who live at the expense of others.
Human rights are a very different story. Rights are normative, they embody the claim to equality even if they are distorted by powerful interests. This is why the appeal to human rights always presses for a policy of equity, while the logic of security is satisfied by walling off. However, walling off brings dangerous effects on those within. The dream of absolute security, according to Achille Mbembe, a philosopher living in South Africa, means not only monitoring but also cleansing.
And scapegoats, who are then made responsible for the spread of diseases, are easily found – earlier, the Jews, today, the migrants.
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What would it be like to follow the other approach? Creating equality in a global context? With more development aid? Aid which ultimately only serves the interests of the donors and traps recipients in new dependency? Real change requires a different setting. Utopia here is not a matter of increasing the budget for development aid, but of effective systems of redistribution which transcend all borders, based on the principle of solidarity. This is the only way that “structural violence” which peace researcher Johan Galtung has described as “avoidable insults […] to life” can be effectively countered.
Given the level of globalisation we have reached, it is high time to think about new international agreements which make possible equitable use of available resources. We need redistribution mechanisms which deliver equality based on the principle of solidarity between low-income and high-income countries. In any event, countries like Sierra Leone will be unable to master the health challenges they are currently facing from their own resources. In 2010 the WHO listed 41 countries which are too poor to meet even minimum health standards. So long as this is the case, the gap between demand and the available funds must be met from outside support.
A few charitable gestures are not enough to bridge this gap. We need reliable institutions which establish equality across borders. What I have called “cosmopolitan health insurance” could contribute to such equality. However, the term is not entirely accurate, as it does not involve insurance, let alone a private insurance scheme, but an “International Health Fund”. What this means is compensatory funding embedded in international law which commits richer countries to contributing to the social protection budgets of the poorer countries. An important word here is “commits”. The goal is not to increase development aid but to establish equality based on the principle of solidarity which is secured by international treaty.
Such revenue sharing does not require an extensive bureaucratic structure. All that is needed is a small institution operating in the background which abstains from all operational activities and only organises the bundling and transfer of funds. The German system of interstate fiscal equalization scheme is an example of how this can work. By balancing out factors including regional tax revenue, demographic trends and income levels, it levels-out the financial options of the federal states.
Funding through financial adjustments need not perpetuate existing gaps. Recipients can become donors, and vice versa. Bavaria, which was a net recipient in the post-war decades, provides funding today for other federal states. The fact that Bavaria would now prefer to end interstate financial adjustments completely shows how far the neoliberal ideal of autonomy and competition has taken root in politicians’ thinking.
Even if virtually no public attention is paid to the interstate funding, the level of the transfers through this mechanism is now substantial. The European Social Fund, founded 60 years ago in order to achieve equality in education, unemployment benefit and other social services between the regions of Europe, currently amounts to EUR 75 billion a year. The ESF agency in Brussels is in no way an overblown bureaucracy, and also only organises the provision of funds. All operating decisions, which well over 100 million people have benefited from in past years, are taken by the member states themselves.
A financial adjustment mechanism also exists at international level, unnoticed by most people. A very old one, even. In 1874, national postal authorities created the “Universal Postal Union”, the heart of which is a treaty which makes the delivery of letters and other mail possible across national borders. A charge collected in one country finances services in other countries. Within this framework, the German post office pays a substantially greater amount than e.g. the Kenyan post office. Hardly anyone is still aware of the existence of the Universal Postal Union, although its creation was a milestone in the development of international communication. The most important public goods are those which perform their task without a lot of fuss. In a manner of speaking, they exist in the social background. Recently, however the Universal Postal Union made the headlines again, when Donald Trump announced to an astonished world that the USA was going to withdraw from the treaty, because it was hurting the USA.
Financial adjustments are only effective in the long term if they are supported by binding agreements. The certainty of support lasting for years is the only way that e.g. social authorities and health administrations in Africa can plan and establish multi-year programmes. These include programmes which initially require substantial initial investment, but which can be self-supporting in the long run. Financial adjustments need not promote inaction, as their opponents are now claiming. Indeed, if anything the opposite is true.
The opportunities arising out of the creation of “global universal insurance” are great. They could lay the foundation for a social infrastructure on the global scale which ensures access for all to essential public goods such as education, health, mobility or culture. Such forms of institutionalised solidarity have nothing to do with private charity or development aid governed by special interests. They are a question of reliable structures securing legal rights. None of us feels that we are a recipient when we send our children to school, and we would never think of regarding the school authorities as a patronising donor. To make essential public goods such as education, culture, health etc accessible to all, they must be financed on the basis of solidarity.
And this is the reason why the idea of a “Cosmopolitan Health Insurance Scheme” is fundamentally different from the project for “University Health Coverage” currently favoured by the WHO and the World Bank. This is not intended to be funded through a contractually regulated redistribution of existing resources, but essentially by the countries themselves, or through private investment, which would leave the door wide open to the relevant insurance industry. By contrast, financial adjustments as a requirement for a social infrastructure create a social sphere which in principle operates outside the capitalist economy.
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I have been advocating the idea of financial equalization schemes since 2001. While reactions were originally mocking (he’s gone crazy), things have changed. Today, even critical health policy specialists, development planners and international lawyers are talking about the idea. In September 2012, Anand Grover, at the time UN Special Rapporteur on the Right to Health, reported to the General Assembly and called for just such international health financing based on solidarity.
Since then, there has been growing willingness to deal with the questions of implementation, namely questions of the ability to finance, democratic ownership, and also the prevention of abuses.
The fact that funds are not lacking is supported by WHO’s figures. Annual expense on health was around USD 6.5 billion, or some USD 950 per capita and year, significantly more than the USD 12 available to e.g. an inhabitant of Eritrea. Around USD 1 billion currently goes into the coffers of the wellness industry (focus on cosmetic and anti-aging services) while less than half of this would finance basic medical services for all. According to the WHO, around USD 60 per capita and year is needed to provide such services for everyone in today’s poor countries. This would even be possible with the internationally agreed 0.7% goal for development cooperation.
In Germany, we spend over USD 5,000 per capita and year. But not everything which we take on ourselves or which is expected of us is even needed. Spending on drugs could be cut by almost half if they only cost as much in Germany as they do in the UK. The pharmaceutical industry makes EUR 5 billion additional profit in Germany through sales of overpriced and useless medications. Many billions could be saved if the use of pointless diagnostic devices was also stopped, and the notorious billing fraud and present corruption now widespread in the healthcare sector was stopped. Something else worth considering is decluttering personal lifestyles, as recommended by Harmut Rosa, given that consumption of wellness services can also be a form of exploitation, and that stressful working environments can make you ill, and that less can be more. Ultimately, there has to be something in it for everyone.
It is clear that “Cosmopolitan Health Scheme” can only function if it is structured and controlled democratically. To prevent transferred funds from vanishing into repressive state organisations or through corruption, civil society, structures are needed which understand health in the context of social equity and democratic participation.
Decisions on health priorities must not be left to expert committees; rather, they require a maximum of democratic participation. Among other issues, this requires discussion of what constitutes public goods, of which we hear so much today. Are these “primary goods” which have to be provided by the state through a top-down approach, or is this a “joint process” of determining together with the community what health and health services mean for them. The two are not necessarily mutually exclusive. While it is necessary to organise bundling of resources centrally, and now even internationally, it is equally important that the authority deciding on the use of funds be located as far down as possible. In Scandinavian countries, it is the municipalities which determine, in public debate, what they want funds transferred for preventive health purposes to be used for, whether to build a sports hall, lay out a fitness path or provide advice in schools on nutrition.
This is how cosmopolitan social protection not only promotes a model which counters transforming health into a commodity, but contributes towards reviving the democratic process which is extensively blocked today, at both the local and global levels. Creation of global institutions is one of the prerequisites for facing up to the crisis of democracy defined in terms of nation states.
The goal is to create global relationships, as Immanuel Kant wrote earlier. Relationships where human rights emerge from the underlying idea. Relationships where the possibility of a global evolution of the world takes on concrete form.
Thank you.
