The global context

The Alma-Ata Declaration in 1978, adopted in the International Conference on Primary Healthcare was conceptually a historical breakthrough to establish health as fundamental human right. The state was expected to play the primary role to ensure the right through universal health coverage adopting a health care system based on equity and social justice. Despite their commitments, most of the states failed to safeguard the health of people and surrendered before the tide of the market and increasing privatization of health, while the commitments of Alma-Ata gradually faded. Social justice, equity and rights of citizen to health were almost wiped out resulting in widening gaps between people living in different socioeconomic circumstances. Deprivation and marginalization of that section of people continued, which are reflected in unequal global and health indicators. In view of this, it is apparent that Universal Health Coverage based on equity is more relevant today than before, as we live in the most unequal world in the era of austerity. This relevance is well reflected in the notion of the comeback of the Alma-Ata commitments as Revitalization of Primary Health Care with people’s initiatives at the global level.

The Nepal Context

Nepal, a small in territory with less than thirty million people, a low income country, lies between two emerging powers – India and China with nearly two and half billion people. Experiencing a decade long armed conflict, Nepal faced series of political and economical hardships. Despite its size and development status, Nepal could not remain untouched from the global wave of privatization of health care. Soon after replacement of absolute monarchy by restoration of a multi-party political system in 1990, the country adopted neoliberal economic practices with massive privatization of health care services. Due to the weak state system and operating machinery to regulate the private sector, the market grew rapidly in a short span of time. More than half of the doctors and nurses, more than two third of the pharmacist are engaged in the private sector, more than half of the hospital beds in the country are owned by the private market [1]. Growth of the market not only dominated health services, it also influenced state policy and planning in its favor. This policy was based on the theory that people are willing and capable of paying for health services, Nepal introduced user’s fee in the public sector hospitals and healthcare in the name of cost recovery and sustainability. While the private market served the urban elites, even the public services were accessible for those with purchasing capacity. A vast majority of poor people, urban or rural, were deprived of health services. The deprivation of health services due to inability to purchase health services has been one of the determinants of disparity in health, which exists between the ethnic groups, people living in different ecological zones of the country and between the people living rural and urban settings [2].

Nepal enjoys an appreciation at the regional level for remarkable progress in implementing Millennium Development Goals (MDGs) 4 and 5 related to health indicators in terms of declining mortalities[3]. A brief snapshot of statistics in Table 1 reflects this change over the last two decades.

Table 1. Decline of mortality in Nepal

Reduction of mortality has resulted in visible increase of life expectancy which increased from 53 years in 1991 to 68 years in 2011. However, it is still short and there needs to be a serious review of the underlying causes. Contribution of critical awareness among the people and initiatives beyond the health sector are ignored and pushed aside while appraising these improvements. Even more important, progress in gross national average has masked the disparity in health across the country and people. Just taking these few mortality indicators into account, as mentioned above, discrepancy is considerable and sustained for many years.

Table 2 Disparity in mortality among the people

Struggle of Nepal to de-privatize health

It is well understood that strengthening the public sector is a pre-requisite to reduce the influence of the private market in health. Difficult topography, poor infrastructure development, inadequate human resources are major hurdles for Nepal to provide health care services to the people. Technical competencies, managerial efficiencies and governance are other dimensions of the problems that can never be ignored. Amidst these challenges, financing health is considered as the primary agenda of the struggle to meet the goal of Universal Health Coverage. Financing health is the primary agenda in view that it is interrelated to the fundamental aspects voiced since the Alma-Ata Declaration – equity and justice in health, health as a right of citizens and the role of the state.

A theoretical question ‘who pays for the health care services’ is irrelevant for Nepal, since the country has constitutionally accepted the capitalistic mode of production and distribution, where the cost of health services, like any other services, is borne by the citizen. Apparently, even so called free services are myths, as the cost of services is paid for by the citizens in different forms of tax. Therefore, ‘how to pay for the health services’ is the question and Nepal is struggling to seek the answer. Finding an appropriate answer is vital to replace the direct payment for services to the private market or to the public service facilities at the time of service consumption. Needless to mention that the market does not recognize equity and justice. Therefore, deprivation of services is the ultimate fate of people who cannot purchase these services.

Nepal’s alternative health financing approach

Nepal is in the initial phase of reforms for health financing approach. The reform is seen as a struggle for making a financing approach that will ensure Universal Health Coverage based on principles of equity and social justice. It aims to establish a system where citizen should pay for the health care services based on their ability to pay and will receive the services according to their needs; it is guided by the principles that consumption of health care services does not depend on the scale of their financial contribution to the system and the consumers do not pay for the services at the point of service consumption. Universal Health Coverage comprises of health care services of two categories – Basic Health Services (BHS) and beyond Basic Health Services.

Basic Health Services

It was an achievement of peoples’ struggle that Nepal abolished user’s fee in essential health services and declared these services free. Further, with a collaborative mobilization of civil society, professionals and academics, it was included in the Constitution. Thus the state defined Basic Health Service is guaranteed by the Constitution of Nepal as a fundamental right of citizen[4] and provided by the public health facilities at all levels free of cost . The fund for Basic Health Service is allocated by the state as a part of the national budget collected from general taxation based on the scale of income of the citizen. People do not pay tax particularly for health. Basic Health Service is equity based. As the scale of Basic Health Service depends on the size of the health budget, Nepal struggles to increase the state health budget and expand the package of Basic Health Services.

Beyond Basic Health Service

Financing beyond Basic Health Service is a challenge for Nepal, as the state cannot bear the cost of burden of health problems, which include a large portion of secondary care and nearly entire tertiary specialized care. People have to pay for services even in the public hospitals, where services are inadequate. Hence, people are largely dependent on the private market. These services are expensive. Poor Nepali people cannot afford the cost of services, which is catastrophic for many of them. Ensuring access to these services to the people is the epicenter of the struggle of Nepal to meet the goal of Universal Health Coverage. It includes sustainable financial provision and a structure with human and commodity resources. However, as mentioned above, financial provision remains the primary agenda.

Creation of public fund for beyond Basic Health Service

The Government of Nepal introduced the Health Insurance scheme in 2013 for creating a fund to cover costs for beyond Basic Health Service. The scheme raised the fund as premium in equal amount from families regardless of their economic status for enrollment in renewable health insurance schemes. The insured family could receive health services at a limited cost. It was a market model insurance – same price for all – and, therefore, did not comply with the principle of equity and justice. Paying the same amount of premium by poor and rich family for similar health services did not reflect the spirit of Universal Health Coverage.

The scheme was harshly criticized for its regressive nature since it marginalized the poor sector of the population further depriving them of access to health services. The need for a public fund to cover the cost of beyond Basic Health Care was undeniable. A strong public voice was raised for creating the fund guided by the principle of equity and justice. It was proposed that the contribution to the fund be based on the economic status and purchasing capacity of the family. There were reluctant views on such basis of contribution. There was also an argument on the capacity of the state to assess and monitor the ability of the family to pay.

As a response to the voice for people, despite objections, the parliament recently passed the Health Insurance Act 2017 with the provision of financial contribution to the fund by the family to be based on their income status. It is a legal indication that the fund for beyond Basic Health Services would be raised through the progressive taxation model in the coverage of health insurance. The Act also provides the legal provision that the government will pay the premium for families, who are below the poverty line as defined by the state[5]. This will ensure the inclusion of all citizens in the scheme regardless of their earning and economic status. It will provide the financial protection to the poorer section of the population and help to achieve the goal of Universal Health Coverage. It is note-worthy that people pay for health services based on their ability; for basic health services non-specifically as general tax, while people pay for beyond Basic Health Service specifically for health as premium.

Conclusion

Nepal has achieved a financing mechanism based on the principle of equity and social justice to ensure Universal Health Coverage to every Nepali citizen because of peoples movement and struggles. However, implementation remains the challenge and unfinished agenda. Despite the engagement of the private market in social health insurance schemes, it is expected to minimize the adverse impact of privatization of health services through the control of the state over the market. There is a reluctance regarding the progressive tax based health insurance, and there is widespread lack of trust about the ability of the state to implement the system. However, this is not the time to raise the question whether the state can provide basic health care not; it is rather a prime moment to ask whether the state must do it or not.

*** Sharad Onta, MD, MPH, PhD is a Professor of Community Medicine and Public Health at the Institute of Medicine, Tribhuvan University, Kathmandu Nepal, member of the Faculty Board (highest academic authority of the Institute). Sharad is also the author of several scientific papers and chapters of books on public health and health policies.

[1] High Level Commission on Health Profession Education 2015 Government of Nepal, Kathmandu

[2] Nepal Demography and Health Survey 2011 Ministry of Health, Government of Nepal, Kathmandu 2011

[3] National Health Policy 2014 Ministry of Health, Government of Nepal, Kathmandu 2014 *Analyzed from NDHS Report 2011(2)

[4] Constitution of Federal Republic of Nepal 20

[5] Health Insurance Act 2017, Government of Nepal

SALIENT POINTS AND WAYS FORWARD

Amidst this gross and rising inequality of 62 people owning as much wealth as 3.6 billion of the poorest people in the world, amidst massive unemployment and work informalization which is becoming structural. Workers’ families have barely any access to affordable, accessible and quality public services – like universal health care, free education up to the college level, decent public housing, a living requirement of water and power, and reliable public transportation, among other public essentials

We need to answer the plea, can we achieve a dignified life for all? People, as human beings have the inalienable right to essential services. These are public goods and part of our social commons. They are vital to life, to the dignity and development of individuals and society as a whole. Their provisioning must therefore be guaranteed.

Yet, the World Bank and IMF continue to impose conditionalities that cut public spending and require privatization of public service financing and delivery. Inequitable trade agreements lock in privatization and expose our governments to the risk of costly arbitration in one-sided international tribunals. States continue to retreat from their obligation to guarantee and finance decent public services.

However, a movement to reclaim public services is sweeping Europe and gaining momentum in Asia. Inclusive people’s platforms and unions, academics, local officials, parliamentarians and policy-makers have taken up the challenge of reversing the privatization of public services and returning them to public ownership and democratic control. International campaigners and scholars have joined with Philippine counterparts in Manila to share insights and experiences.

Together, we have deepened our understanding of the mounting evidence that reveals the failed promises of privatization. We affirmed that effective and accountable public services are a powerful tool to promote greater equality, build social cohesion and improve living standards for all.

We shared documentation, including the 835 examples of municipalities that have benefited from replacing privatization by democratic and participative delivery of public services. We have been inspired by those and other alternatives.

This conference has been a great learning experience, and our exchanges have strengthened our advocacies through the sharing of best practice, strategies, tactics and lessons learned. We have identified new initiatives to build a more powerful movement to reclaim public services.

Our discussions have stressed the following:

• We will continue our vigorous and -wide ranging campaigns that will enable us to generate the broadest public support and understanding of our agenda.
• We will widely disseminate our messages and alternatives through the social and mainstream media, and seek to encourage campaigns are covered by in the media.
• The Asia-Europe Peoples Forum will disseminate the Final Statement, papers and video clips through the social media and key outlets in mainstream media, and target relevant state agencies at the national, regional and global level.
• We will continue our painstaking lobby work to grow more advocates among legislators and policy-makers, and unite all groups reclaiming public services through building broad coalitions at the national, regional and global level.

In our discussions, we were inspired by Jeremy Corbyn who urged the immediate social ownership and democratic control of public services, a vision which will require great change in societies and a major social struggle world-wide. Our effective cooperation at the regional, inter-regional and global level is more important than ever.

But the real battleground for reclaiming public services is in the streets, workplaces, communities and villages. In addition to our research, lobbying and movement-building, we will also need to act strongly and directly, through litigation and legal reform, civil disobedience and strikes, national consultations and massive protests, consumers’ actions and boycotts, pickets and marches, among others.

There will be change in national and global policies only when we have strong social movements that embrace the fight for social, economic and ecological justice across countries and across continents. So we will promote broader and stronger forms of organization and mobilizations that can create the compelling pressure from below to reclaim the state, and support our key goals to:

• Introduce legislation, with constitutional underpinning if possible, to ensure that people’s rights to public services are institutionalized and insulated from market forces and political patronage;
• Finance public services by building the political will to enforce real progressive taxation and abandoning unjust tax policies which allow the mega-rich to hide their wealth through tax havens and illegal money flows;
• Abandon the policy of using PPPs, and use public finance to finance infrastructure and public services;
• Establish public ownership and democratic management of public services, including mechanisms for people’s participation and oversight;
• Foster public-poor-partnerships that enable impoverished communities to participate fully in the planning, implementation and oversight of projects.

Lastly, we recognize that rebuilding public services is not an isolated campaign. It is closely linked with struggles for decent work, land and food sovereignty, just trade and climate justice. It is part of the transformative change towards an alternative development paradigm for people and planet, within a more enlightened socio-economic system that, as Naomi Klein characterized, “closes deep inequalities, strengthens and transforms the public sphere, generates plentiful, dignified work and radically reins in corporate power.”

Since 2013, the representatives of the most powerful states in the world have been discussing the TiSA (Trade in Services Agreement) agreement that will include education and health care. In 2014 such negotiations were revealed by WikiLeaks, the organization led by Julian Assange. The TiSA will be the largest trade agreement ever discussed, since services represent about 70% of the world’s GDP. On 4 February 2015 the AWP (Associated Whistleblowing Press agency) published a TiSA document which states the following: “There is enormous potential that is not yet exploited for the globalization of health services”. The health market is valued at several hundred billions. Yet potential gains may be even larger. “Being financed and provided by the State, or other welfare agencies, health systems are of no interest to foreign investors due to the absence of commercial purposes”.

The methods of meeting such an objective are quite easy: privatization, the opening of markets to large financial funds and international insurance companies, thus reducing the public responsibility for collective health. Governments all over the world, even those financing national healthcare services, keep reducing their budget expenses in health issues with the aim to privatize their health system and limit the right to universal, free of charge access to therapies.

THE SOCIAL DETERMINANTS OF HEALTH

According to the WHO, we deem health as “a state of complete physical, mental and social well-being and not just the absence of the state of illness.”

The Global Wealth Pyramid

This is the current social pyramid of the world where 8.2% of the population controls 86.2% of wealth, but above all where 73.2% of citizens have less than 2.5% of the wealth of the planet. The situation worsens yearly. Extreme poverty isn’t only in the southern hemisphere. Poverty, housing conditions, work rather than unemployment affect quality but also the duration of our lives, – in the USA the poorest die 14 years

Source: James Davies, Rodrigo Lluberas and Anthony Shorrocks, Credit Suisse Global Wealth Databook 2016 earlier than the richest.

Look at this slide –

Lenzie and Calton are two areas of Glasgow, less than 10 miles apart, yet, among them, there is a difference in life expectancy of nearly thirty years; thirty years between those living in a poor neighborhood and those living in a residential area and we are not comparing a village in Bangladesh with a Norwegian city. Here’s what it means to evaluate the social determinants of health.

Often in medical conventions one remembers how in ancient China the doctors were rewarded and paid more if less citizens entrusted to their care got sick. Prevention was the main subject of those who approached medical science. Today prevention in the Western world has almost disappeared.

But prevention does not require the use of drugs, large hospitals, sophisticated technology; prevention does not produce big profits, and so this is not in the interest of the market.

Just to give an example: according to UNAIDS, 1.8 million people in the world became newly infected with HIV in 2016 and according to data from the World Health Organization (WHO), published in the World Malaria Report 2016, there were about 212 million cases of malaria estimated worldwide in 2015 and about 429 thousand deaths, 70% of which among children under the age of 5 years (of which 292 thousand in the African Region), followed by Southeast Asia (7%) and the Eastern Mediterranean. It should be noted that tobacco is one of the leading causes of death among non-communicable diseases, but British American Tobacco Company was one of the main contributors to various foundations and political figures.

THE PRIVATIZATION OF HEALTH SERVICES

Every year the financing of the National Health Services in EU grows less and less than it would be necessary even to recover the increase in prices of technologies and services estimated at an average around 2%, and to equalize inflation.

In Greece the effects have been devastating; even countries with efficient health systems and a long tradition behind them have had similar fate. In Spain in 2012 the universalistic system was replaced by an insurance company, in England, with a law that came into force in 2013, the National Health Service was destroyed and the production of services was privatized, in Italy, in Lombardy, the richest region, a recent right-wing government project, is trying to privatize healthcare of 3,350,000 citizens.

The privatization of health increases year by year everywhere, in the future only the rich ones will be able to cure themselves. It is not true that the privatization of health systems produces saving in spending: it simply transfers substantial expenses from the State to the individual citizen.

THE BUSINESS OF DRUGS

A market-oriented approach, as imposed by the multinationals managing the sector, rules the availability and the access to drugs. The aims and the needs of public health don’t count for anything. While multinationals foster the use of useless products, all possible means are provided to limit the access to economical, affordable drugs for millions of patients to whom the use of drugs is denied as these are too expensive. In such a framework, the commercialization of health enhanced by the financial system damages all human beings, in particular the most vulnerable and poor people. Innovative drugs prices are rising without any justification due to their production costs as the patent owners set their prices in a monopoly regime.

Such a situation might become even worse in case the international commercial agreements extend the patent duration, already granted for 20 years by the TRIPS agreements, and will impose more constraints on the concerned countries limiting their power in regulating the market.

If Big Pharma companies have not broken down in the face of $ 14 billion fines sentence in five years for bribery and bogus advertising, it’s because you willingly pay when the crime produces gains many times greater than the penalties!

We ask that States immediately apply the two clauses contained in the TRIPs agreements – the Agreement on Trade Related Aspects of Intellectual Property Rights- that allow a nation to directly produce drugs without respecting patents, when it is not able to guarantee the care of its citizens. I am speaking about parallel importing (art.6) and compulsory licenses (art.31). These clauses are only formal statements, but in their current version they are unusable.

We ask that our governments challenge the TRIPs within the World Trade Organization; it makes no sense to guarantee a production monopoly for twenty years, when in only one year companies can recover all expenses and investments. But this is not enough.

It is not possible to let the pharmaceutical industry be a monopoly of the private sector, it is important to fight to resurrect a public drug industry, even supranational, but public, which aims to cure and not to profit. We have spoken so far of diseases for which there are treatments but are increasingly unaffordable for an immense amount of people. A further issue concerns the so called “neglected diseases”, the forgotten diseases, for which no research is done because they affect poor populations out of the market and for which, in some cases, the drugs are there but are kept in the drawer because they would not produce profits.

CONCLUSION

All these elements represent a clear attack to people’s right to health: the neo-liberal policies supported by the most powerful countries in the world are fully responsible. Defending the right to health, to universal, national healthcare systems, and to the free access to therapies is a way to contain such policies. It is also a way to oppose without any ambiguity those who are part of this economic and financial system.

I believe there is not only a heavy attack on the health condition of human beings driven by the head of political, economic and financial powers, but also on the will to provide suggestions for a global agenda aimed at opposing the privatization of health care systems.

The privatization of health, the appropriation of the human body as a source of income proceeds hand in hand with the privatization of the Common Goods which are indispensable for the survival of mankind and other species, to begin with water and land.

What we are launching now is the challenge to build a long-lasting alliance between a part of the scientific world and social movements because health can have neither masters nor borders.

Ours is not a cry of despair, what we launch is a sign of hope for those who refuse to surrender, for those who do not take refuge in individual solutions, for all those who will be born tomorrow, so that they do not have to curse their existence, but they will still be able to fall in love with the world and the surprises that life will reserve for them.

The neo-liberal wave that was generated by Reagan’s and Thatcher’s policies at the beginning of the 80’s of the last century, did not spare healthcare systems, making them a privileged area for the interests of the market (decline of the public sector, privatization, etc). The World Bank played a crucial role in these processes which affected low and middle income countries at first and later on, in the wake of the 2008 financial crisis and the following austerity policies, the national health systems in rich countries.

*** Vittorio Agnotetto An occupational health medical practitioner, Vittorio Agnoletto is also professor of “Globalization and Health Policies” at the University of Milan, and author of several scientific publications on national and international reviews. He is part of the International Council of the World Social Forum. In November 2017, he was spokesperson of the International Forum for the Right to Health against the G7 Summit. He was a member of the European Parliament, working on human rights and free trade agreements, especially the EU-ACP FTA. In 2001, he was spokesperson of the global movement against G8 in Genoa in 2001. He is founder of the Italian League Against HIV (LILA) and a member of the HIV National and International Committees. He has managed a lot of research projects in Europe and Africa on public health, access to medicines, drug addiction, HIV, and compulsory license. He is also a member of Medicina Democratica (Democratic Medicine) and CostituzioneBeniComuni (Constitution and Common Wealth).

Political declaration

One very clear message came out of this conference: public services should be in the hands of public authorities and citizens and be fully and exclusively committed to serve the society as a whole. Some speakers put emphasis on the role of the state, others on municipalities and still others on citizens and their self-organisations. But they all agree public services must not be made into profit-making mechanisms, such as international institutions and too many governments now tend to do.

The privatisation efforts of the past decades have failed. Many essential services are not affordable for the majority of poor people, quality is substandard, employment and wages are undermined. Research shows that privatisation leads to excess profits for corporations and high costs for the public. Whether we speak of water, health care, education, public transport, energy, in each and every sector the same problems arise.

Moreover, transnational corporations, the drivers of privatisations, do not hesitate to push for free-trade agreements with private arbitration clauses, so that they can sue governments whenever laws or regulations are proposed in the interest of citizens but possibly affecting their profits.

As a consequence of failed privatisations, the conference shared many examples of reclaimed public services that resulted in significant public benefits, including lower costs. 835 examples of services taken back under municipal ownership and control have been documented, demonstrating that the title of the conference ‘Reclaiming public services’ is becoming an exciting reality.

Movements of citizens and residents are getting stronger to reclaim what is theirs: universal quality of fundamental infrastructures and services in the public interest. To make this possible, governments will have to seriously question, in a participatory process, their macro-economic framework and their tax and public spending policies, as well as their unjust laws, so as to make financial resources available. Public services will also have to contribute to the reduction of the disastrous inequalities and to the sustainability of the environment.

Whether these services are provided by States, municipalities or people’s organisations, the way they are conceptualized, regulated and monitored is crucial for their success. Real participatory democracy is therefore an essential and common characteristic of the public services this conference wants to promote, based on the successful best practices.

Public services go beyond public ownership to embrace dynamic forms of democratic participation and accountability. The conference gave examples of democratic planning of inclusive public services, such as for transport, renewable energy and housing.

It means that in this new era with a new awareness of what is necessary for a life in dignity for all, and with a better understanding of the fundamental differences between progressive policies and a neoliberal and conservative ideology, we can overcome the simple divisions between state and market, private and public.

This conference has been a major contribution to the alliance of all progressive forces, working in the framework of the commons, our collective ownership of our common nature and built infrastructure. We worked to re-define strategies, to renew its thinking on production, markets, nature and the State, to create a new narrative to better organize our resistance to neoliberal and conservative forces.

New forms of cooperation are required, between public authorities at different levels, trade unions and other social movements, academics and legal experts. In the same way as this conference was built, progressive forces can make real progress once they understand their common interest. Victory is possible.

Destroying public services is destroying the very society that makes us what we are, social relationships, solidarity and collective values. Preserving and promoting public services is promoting citizenship and the sovereignty of the people.

The world is riven by social injustices marked by worsening social inequality, dispossession, exploitation and exclusion. Concretely, in Asia, despite a booming economy, close to one billion people face massive unemployment and work informalisation, with barely any access to social services and support for a life of dignity. In Europe, more than 115 million people are living on the poverty line, facing indebtedness, joblessness and insecurity. However, states respond with policies that cut social services and dismantle public utilities. Institutionalised welfare programs that have served as models of development have been undermined and eroded.

Austerity Measures

The dominant development paradigm’s market-centric policies have affected the lives and livelihoods of peoples in Asia and Europe, especially the vulnerable sectors. Both regions face austerity measures driven by international public institutions, notably the International Financing Institutions, and in Europe through the European Union which has given the Commission additional powers to slash and control national public spending plans.

Even the IMF now claims to recognize that current policies increase inequality and that this harms economic growth and stability. But the IMF and World Bank continue to worsen inequality by their conditionalities which require cuts in public spending, in spite of their formal priority for poverty reduction. They also promote cutting corporate tax rates and providing generous tax and fiscal incentives, which lead to losing and forgoing badly needed financial resources for social spending. Meanwhile, to recoup these losses, the IMF, in particular,pushes the adoption/increase of regressive consumption taxes such as Value Added Taxes which unjustly burden the poor and low-income groups. Women in great numbers are in lowly paid, insecure, informal work and are thus disproportionately impacted.

This internationalization undermines and weakens democratic processes and outcomes at the national level. Social movements thus face a challenge not only of winning public support and national level political support, but also defending the democratic processes against the institutions of globalization.