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 violence-free 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 well-being.’

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 IIIHegel (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.’

• ‘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 I

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

• 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

• 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

• 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.