In preparation of People's Health Assembly II - part 22
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Neoliberal ideology in the World Health Organization: Effects on
global public health policy and practice
(Part 1 of 4)
Introduction
The infiltration of neoliberal ideology in WHO today is an unde-
niable fact and this is despite WHO's Constitution and many
founding and key documents since then, which are explicitly ori-
ented towards social justice as a solution to health problems.
The WHO/UNICEF Conference on Primary Health Care held in Alma
Ata in the former Soviet Union in 1978, represented the flower-
ing of this vision but the movement was swiftly silenced as
early as 1980.
There are contradictions between WHO's founding principles and
the policies which have been implemented by current office hold-
ers and their predecessors over a 25 year period. A re-
appropriation of this UN agency by the people only requires a
return to its founding principles and values. Nothing needs to
be reinvented.
Moreover, there are new developments which need to be taken into
account. These include massive increases in inequality between
and within countries, accelerating environmental degradation,
and the threat represented by the General Agreement on Trade in
Services (in health and in water services, for example). How-
ever, the fundamental principles, objectives and functions set
out in WHOs Constitution (1948) and above all in the Declaration
of Alma Ata (1978), are still valid today.
But neoliberal approaches to health ignore root causes of both
poverty and disease, betray fundamental public health principles
and produce cosmetic and unsustainable results.
WHO's constitution: health for all through social justice
Let us be reminded:
* "Health is one of the fundamental rights of every human being"
* "The health of all peoples is fundamental to the attainment of
peace and security"
* "Unequal development in different countries in the promotion
of health and control of disease, especially communicable dis-
ease, is a common danger"
* "Governments have a responsibility for the health of their
peoples"
The principles set out in the preamble to WHO's constitution are
critical to a re-appropriation of this UN agency by the people
in their (genuine) effort to achieve Health for All - NOW. In-
deed, there is tremendous potential today for people's health
movements call WHO to account and challenge it to respect its
own mandate. Of particular interest today is the reference to
governments' responsibility for the health of the people which
is a principle ignored or rejected by neoliberal ideology.
Alma Ata and the hijacking of Health for All
The Declaration of Alma Ata clearly identified the social and
economic root causes of preventable ill-health and mortality. It
placed the debate squarely on international power structures and
insisted on a broad public health perspective which addressed
non-health sector determinants of health.
It said:
* "Economic and social development based on a New International
Economic Order is of basic importance to the fullest attainment
of Health for All"
* "Primary Health Care is the key to attaining this target as
part of development in the spirit of social justice." PHC in-
volves "in addition to the health sector, all related sectors
and aspects of national and community development... and in-
cludes promotion of food supply and proper nutrition, an ade-
quate supply of safe water and sanitation..."
The Declaration has never been repudiated although its princi-
ples have often been disregarded during the period of neoliberal
influence. The revolutionary implications of the Alma Ata Decla-
ration and the threat that it represented to the established or-
der were not lost by the rich and powerful. Within a couple of
years, primary health care (PHC) was declared "costly and unre-
alistic" and was replaced by "a selective" version reduced to a
few high priority technical interventions determined not by com-
munities, but by international health experts. This allowed gov-
ernments and health professionals to avoid dealing with the so-
cial and political causes of poor health and thus to preserve
the inequities of the status quo.
Neoliberal and social justice approaches to health: a comparison
Neoliberal approach to health
Underlying assumptions
1. Economic growth, within a globalized "free" market is the aim
2. Health is what you get from a health service
3. International aid, with conditionalities to enforce certain
policies, is the only way to finance health
4. Democracy is alive and well in the developed world and is the
model for the developing world
Key features
* Addresses symptoms, short term
* Promotes 'silver (medical) bullets'
* Promotes interventions delivered through health services
* Identifies charity and international aid as only sources of
funds for health
* Maintains the status quo of extreme concentrations of wealth
and power
* Focuses on individual behaviour and tends to blame victims.
Social justice/human rights approach to health
Alternative assumptions
1. Fair distribution and sustainable use of resources is the aim
2. Health is what you get from meeting basic rights
3. Sovereign states must provide for their people's rights with-
out outside interference
4. Democracy is in crisis everywhere. Self determination of na-
tion states and a rules-based system of international governance
are required
Key features
* Addresses root causes, long term
* Promotes the meeting of people's health rights
* Promotes public works to free people from miserable living
conditions
* Identifies income redistribution and economic justice as
sources of funds for health
* Demands a fair and rational international economic order
* Focuses on structural poverty and violence and finds the
causes of them in the system.
Neoliberal reversal of public health logic and history
In the neoliberal approach to health, focusing on a few major
diseases is said to resolve key public health problems. But as
Pasteur said: "The bacteria is nothing: the terrain is all".
The relationship between health and poverty is two way but it is
not symmetric. Poverty is the single most important determinant
of preventable ill-health. Conversely, poor health is very far
from being the single most important determinant of poverty!
Poor health exacerbates existing poverty.
No amount of good medical care delivered to Haitians or Tanzani-
ans today is going to make them or their country prosperous to-
morrow if the national economy is strangled by debt, unfair
terms of trade and the continued pillage of natural resources
and is destabilized by uncontrolled financial outflows, wildly
fluctuating commodity prices and outside interference in matters
of national sovereignty.
On the other hand, substantial and sustainable improvements in
public health are achieved by meeting the basic material needs
for food, water, sanitation and shelter, as well as basic social
needs for education, employment, access to land, safety and se-
curity --i.e., addressing the root causes of preventable ill-
health and death. However, meeting basic needs for health re-
quires redistribution of resources and a radical transformation
of economic and political arrangements the world over. This is,
of course, deeply threatening to powerful elites.
A.K.