Shifting Polices and a Clarion Call for the Accountability of Non-State Actors in Health Policies
E.PREMDAS PINTO
Shifting sands’…
This term could best describe the ever shifting global health policies and priorities in recent years. Within a short span of time the buzzwords in health and health care have changed several times – health as a human right, comprehensive health care, selective health care, universal health coverage, financial protection, Millennium Development Goals (MDGs) – and the current buzzword is ‘Sustainable Development Goals’ (SDGs)! The euphoria of MDGs and SDGs, paradoxically however, is also marked by the alarm caused by Ebola and Zika viruses, in addition to the continued deaths of millions due to entirely preventable communicable diseases such as diarrhea, tuberculosis and malaria, maternal deaths, and ethnic conflicts and refugee crises. As accountability practitioners, the fundamental question we ask is – why is this allowed to happen? What is the link between these shifting policies and the preventable yet unabatedly continuing morbidity and mortality? Beyond rhetoric, does the current discourse of SDGs address the underlying causes or strategies to achieve the same?
The inevitable link being pointed out in recent research is the growing role played by non-state and private-for-profit actors in setting priorities in the global as well as national spheres, which has had damaging consequences on the health care system of many low and middle income countries. The shrinking of the public health care sector occurs in tandem with the unregulated expansion of the private health care players in an environment facilitated by state policies. In many countries the poor and even their governments find themselves caught between the devil and the deep sea! They are either left at the mercy of the benevolent aid agencies or face the onslaught of the private health care providers. The inevitable consequence of these developments is a fragile public health care system.
The spread of Ebola virus and casualities in African countries are a grim reminder of the consequences the absence of a strong public health system can have on a society. A robust, vibrant, sensitive and responsive health care system which respects the needs and rights of the most marginalized is a sine-qua-non to respond to people’s health in normal times and in emergencies. Is the health care system in Latin America strong enough vis-a-vis the African countries to respond to the onslaught of the Zika virus? We are yet to find out. What we have learnt from the epidemics, though, is an ever enduring lesson that the preparedness of a health care system to be responsive in emergencies will depend significantly on its optimal functioning in providing preventive – promotive –curative – rehabilitative care as routine entitlements to the people.
The current accountability framework is placed within the state-citizen relationship and presumes the responsibility of the state towards the welfare of citizens. In a state with subdued role in making policies for the welfare of its citizens, or constantly being under undue pressure of non-state actors, or worse still, when the state itself is taken hostage by the non-state actors and policies are dictated by them, the citizens are rendered completely helpless. They will continue to face double jeopardy, viz. non-availability of services from the public sector and exploitation from the unregulated private sector. As most of the public services now have the participation of for-profit-private and other non-state actors in varying degrees, and in health care at times they account for the continuum of services with a referral from public to the private, the accountability discourse requires that the private and non-state actors are now brought within the ambit of social accountability framework. Fixing of the regulatory framework is the first step in such a venture, without which, calling for the accountability only of the state to meet policy outcomes becomes an empty rhetoric.
As MDGs now turn to SDGs one wonders: ‘What has changed?’ The questions that we ask or the answers that we seek or the strategies we pursue? While the participation of the private sector is being encouraged through the SDGs, one is concerned about whether sufficient attention is being given to address its lack of regulation in the pursuit of meeting the new goals? Are the terms and conditions of such participation negotiated on the basis of equity and human right to health care? To what extent have such negotiations been successful in making the profit motive of the private-for-profit and non-state actors subservient to the cause of health and wellbeing of all people, especially the most marginalized? The global policy makers such as the United Nations are now required to turn their attention to this issue if they are serious about changing the lives of people through various initiatives such as SDGs.
This COPASAH Communiqué (edition 13, January 2016) comes to you in a rapidly changing, challenging and ambivalent global scenario. The experiences and stories from the various practice nodes of COPASAH bring out the tireless efforts of empowering communities and strengthening the health care systems through the framework of social accountability in health. Usage of various strategies and multiple experiments in addressing the challenges in accessing health care continue in South Asia, Eastern Europe, Eastern and Southern Africa and Latin America. We believe that what will sustain the SDGs is the strength and power of the communities, the democratization of health care systems, fixing the responsibility of the non-state actors and establishing a health system which are accountable to the people. We need community oriented policies and programmes in an era where fragmentation is engineered in innumerable ways.
We do hope all our readers will appreciate the richness of the stories of practice from diverse communities of accountability practitioners across the globe.
About the Author
Edward Premdas Pinto is the Global Secretariat Coordinator for COPASAH. As an Advocacy and Research Director at the Centre for Health and Social Justice (CHSJ), India, he facilitates the thematic area of social accountability with a special focus on processes of community and accountability in health. He also coordinates the South Asia region for COPASAH. He is a Human Rights Advocate and Public Health practitioner, scholar actively engaged in processes of social justice issues of the communities of Dalit women, rural unorganized labourers and other disadvantaged communities for the last 22 years. To know more about the work of CHSJ and COPASAH please visit, http://www.chsj.org and http://www.copasah.net