[DEBATE] : (Fwd) Neolib Mexican health minister to head WHO?
pbond at mail.ngo.za
Fri Oct 20 09:56:13 BST 2006
WHAT IS HAPPENING AT THE WORLD HEALTH ORGANIZATION?
The Coming Election of the WHO Director-General
Professor of Health and Public Policy, School of Public Health, The
Johns Hopkins University; Director of the Public and Social Policy
Program, Pompeu Fabra University – The Johns Hopkins University;
Founder and Past President of the International Association of Health
Policy; and Editor-in-Chief of the International Journal of Health
The Increasing Influence of Neoliberalism at the WHO
>From World War II until the early 1980s, the World Health Organization
was an important point of reference for those in the international
community who were concerned with the health and well-being of
populations. During the postwar period, the WHO subscribed to the
dominant consensus in the international community that government and
the public sector were responsible for guiding economic and social
activities and correcting the social inequalities created by
unrestrained market forces. This active role of the public sector led
to establishment of the welfare states in the developed countries and
to the planting of seeds for breaking with underdevelopment in the
countries of the developing world. As a consequence of these public
policies, the populations of both developing and developed countries
experienced significant improvements in health and social conditions.
The high point of the WHO of those years was the approval by the World
Health Assembly of the Alma-Ata Declaration (1), which stated that
health required a public health approach, much broader than medical
care interventions. This declaration was followed by many specific
proposals that emphasized the social, economic, and political
determinants of health. Needless to say, some of these proposals had
their problems, but the approval of the Alma-Ata Declaration was a
major step toward redefining the health interventions that are needed
to improve the health and social conditions of populations. And in
many countries, those improvements did indeed occur (2).
In the 1980s the world's political climate changed, with the coming
of the neoliberal "revolution." This change had its beginnings in the
late 1970s, with the administration of President Carter – described
by the New York Times as the most conservative of all Democratic
presidents ¬– and strengthened under President Reagan in the U.S. and
Prime Minister Thatcher in the U.K., then under Presidents Bush Sr.,
Clinton, and Bush Jr., and Prime Ministers Major and Blair. This
"revolution" brought a weakening of the public sector and a
strengthening of private forces that, following the dictates of the
market, shape the nature of our societies according to the wishes of
those whose consuming power reigns supreme in the economic and social
spheres. The improvements in health and social well-being that had
begun in the postwar years were considerably slowed down, and even
reversed in many countries. The evidence for this is overwhelming (3).
The neoliberal revolution in the health sector has meant reduced
public and social expenditures, deregulated labor and financial
(banking and insurance) markets, privatized health services, a
dismantling of publicly funded and publicly provided health services,
and the preeminence of health insurance; these are the new
instruments for responding to people's health needs. Patients become
"clients"; public provision of services is replaced by private
competition and the market. The neoliberal revolution also brought
abandonment of the public health approach, except for public health
measures that focus on individual behavioral change. These neoliberal
practices have been actively promoted by the governments of the U.S.
and the U.K. (which generated the Washington Consensus) and by the
international agencies over which these governments have enormous
influence – the International Monetary Fund, the World Bank, the World
Trade Organization, and, indeed, the World Health Organization (4).
The maximum expression of the ideological revolution taking place at
the WHO is evident in the 2000 report Health Systems: Improving
Performance, prepared under the direction of WHO official Julio Frenk
and WHO consultant Christopher Murray (5). This report established the
neoliberal narrative as official WHO policy. In the Health Systems
report, countries are ranked according to the performance of their
medical care systems, based on highly questionable criteria, clearly
rooted in a neoliberal agenda. For example, in Latin America,
Colombia, which had introduced health insurance (at the advice of
Frenk as a paid consultant to the Colombian government), was ranked
first in performance, while Cuba ¬ – despite having health indicators
and health systems performance recognized as outstanding by most
experts – and other countries with national health services were
placed at the bottom of the list. In this scheme, health insurance was
in; national health services were out.
To satisfy the ideological position from which they started, Frenk
and Murray went to great lengths to manipulate the data, achieving new
highs in the art of distortion and creative accounting – a practice
that some of us denounced in the Lancet (6,7,8). These highs of
manipulation, in fact, exceeded the ethically acceptable, and
Professor Philip Musgrove, technical director of the study supervised
and directed by Frenk and Murray, resigned in protest and publicly
denounced the statistical manipulation in the report, a statement that
was also published in the Lancet (9). It is unfortunate that integrity
such as that shown by Musgrove, in denouncing unethical practices at
the WHO, is uncommon among WHO officials. Political and economic
pressure are exerted on the WHO by powerful governments (especially
the Bush and Blair administrations) and economic lobbies (ranging from
pharmaceutical companies to the food industry). As a consequence, the
WHO no longer provides much leadership in public health. When there is
leadership, it usually comes from elsewhere, and the WHO follows,
reluctantly and quite late. A recent example of this timidity on the
part of the WHO was its very late support for the use of generic drugs
to treat AIDS patients in developing countries, due to opposition to
generics by the pharmaceutical industry. The WHO's accommodation to
neoliberal dogma and practice has damaged its social relevance. It has
become more a part of the problem than part of the solution.
Of course, the WHO continues to do good work in many areas, such as
establishing the Commission on Social Determinants of Health (10). But
even there, the commission seems reluctant to take controversial
positions, and it avoids or ignores research (and authors),
institutions, and positions that may be seen as too controversial
(11). In some cases, the degree to which the WHO caves in to the
neoliberal establishment is breathtaking. The Commission on
Macroeconomics and Health, set up by past WHO Director-General Gro
Brundtland and presided over by Jeffrey Sachs, is one such example.
Sachs is the U.S. economist who pushed for deregulation of the Russian
economy along neoliberal lines after the collapse of the Soviet Union
– changes that were responsible for half a million deaths in two
years. The choice of Sachs as chair of the Commission on
Macroeconomics and Health is a vivid example of neoliberal influence
at the WHO (12,13).
Election of the New Director-General
In early November 2006, a new Director-General of the WHO will be
elected. This is an opportunity to select a Director-General who will
help to reverse the organization's trend toward neoliberalism in the
health arena, one who will stand up to powerful governments and
powerful lobbies, providing the moral and scientific leadership to
defend the principles of the WHO Constitution.
As expected, the Bush administration and other neoliberal governments
are rallying around Julio Frenk as favorite candidate for that
position. If this mobilization is successful, neoliberal forces will
achieve quite a triumph: a well-known neoliberal, Julio Frenk, in
charge of the World Health Organization. After leaving the WHO, Frenk
became Minister of Health in Mexico's right-wing government, under
President Vicente Fox. The Fox government's public policies have been
pure neoliberalism. They follow the "structural adjustment policies"
advocated by the International Monetary Fund and the World Bank, which
include reducing public expenditures, reducing taxes for the richest
sectors of the economy (a proposal eventually rejected in Mexico under
pressure from popular mobilizations), and deregulating the labor
market. During Fox's tenure, inequalities in Mexico, already high,
increased remarkably. Mexico has some of the highest income
inequalities in Latin America. The top income decile of the population
has more income than seventy percent of Mexico's population. The Gini
coefficient, a measure of inequalities, shows the further increases in
inequality in 2002-2005, under the Fox government. In fact, the growth
of inequalities is most likely even larger than suggested by the
figures published by the National Institute of Statistics, given the
significant underreporting of income among the top income brackets.
According to the World Bank, 20% to 30% of Mexicans live in extreme
poverty (on $2 a day), and 60% are poor (living on less than $5 a
day). During the Fox administration, the number of people living in
extreme poverty increased by one million. Meanwhile, the top decile,
and particularly the top 1%, of income holders have enjoyed
unprecedented increases in income (14).
Julio Frenk has been part of that government and therefore shares
responsibility for the policies that have increased inequalities and
poverty in Mexico. Frenk is also known in Mexico as the "privatizer."
As one would expect, his reforms have included the introduction of
markets and competition in the health sector, with the use of vouchers
and similar instruments that have been discredited as ways of
assisting people most in need of health benefits coverage. Behind the
market rhetoric, Frenk's clear purpose has been to introduce health
insurance, contracting out health service provision to professionals
and institutions that, in theory, will compete for "clients."
Actually, as indicated by Professor Cristina Laurell of the University
of Mexico, one of the most respected public health researchers in
Latin America, such insurance-based system have increased regional and
social class inequalities in Mexico, without resolving the huge
problems of lack of health benefits coverage.
There was an alternative to this neoliberal program for Mexico: a
universal, publicly financed national health service, funded by
progressive taxation. This alternative was never considered because it
would be opposed by very powerful forces (including the insurance
industry and the medical establishment) that supported Fox's election.
Fox and Frenk are representatives of the "neoliberal model" in Latin
And now, it is an indication of the power of the neoliberal
establishment that Julio Frenk is considered the leading candidate for
Director-General of the WHO. Imagine the enormous opposition if the
Minister of Health of Cuba or of Venezuela, for example, had been a
candidate for the position of WHO Director-General. We would have seen
an immediate and massive mobilization by the U.S. and U.K. governments
against such candidates, as being "too far left," "outside the
mainstream of the international community"– even though Cuba has done
a remarkable job in its health sector and has shown a commendable
commitment to international health assistance, and even though
Venezuela's health sector reforms are producing spectacular
improvements in health for the country's most vulnerable populations
(15,16). The reforms instituted in both of these countries are far
more relevant to developing countries than are Frenk's reforms in
Mexico. Why would the Ministers of Health of Cuba and Venezuela be
seen as "too far left" to be elected, while the Minister of Health of
Mexico, at the opposite extreme of the political spectrum, is seen as
a good, "reasonable" candidate? For public health workers familiar
with the problems of developing countries, Mexico and its neoliberal
reforms cannot be considered a model for other "poor" countries. To
the contrary. Mexico has shown how not to reform health systems.
The Surprising Support of the Lancet for Julio Frenk's Candidacy
To the surprise of many who work in the field of public health and
health care, Julio Frenk's candidacy for WHO Director-General has been
actively supported by the Lancet. The journal has recently published a
self-serving article by Frenk that promotes his neoliberal reforms in
Mexico (17), and it has explicitly supported and endorsed Frenk's
candidacy in a recent editorial (18). Before that endorsement, the
senior editor of the Lancet participated in a conference in Mexico
organized by Julio Frenk, basically to promote his candidacy.
Lancet's support for Julio Frenk is surprising and disappointing for
three reasons. First, the Lancet is the forum where Frenk's unethical
practices in preparing the WHO report Health Systems: Improving
Performance were made public. Thus the Lancet is fully aware of
Frenk's practices, but is ignoring them.
Second, the Lancet has a longstanding progressive tradition, which
for many professionals is a breath of fresh air, a refreshing
alternative to the profoundly conservative medical journals,
especially in the U.S. Indeed, many health professionals in both North
America and Latin America promote the Lancet as a progressive
alternative to the New England Journal of Medicine, which has
practically eliminated all progressive voices from its pages. It is
because of this tradition that the Lancet's support for Julio Frenk –
a minister in one of the most pro-Bush governments, with a commitment
to spreading the Washington Consensus worldwide – is widely perceived
as a major departure from the journal's progressive tradition.
And finally, the criteria presented by the Lancet to justify its
support for the candidacy of Julio Frenk exclude major qualities
required of any WHO Director-General. The Lancet presents its
criteria in two broad categories, "technical and administrative."
Among technical competencies, it includes (a) experience of global
health practice and/or research, (b) ability to translate scientific
evidence into policy, and (c) experience in managing health systems
(meaning, in fact, medical care systems) in low- or middle-income
countries. These three "technical" qualities emphasize experience in
policymaking and management. To these three technical criteria, the
Lancet adds three administrative skills, which, again, boil down to
experience: (a) strong policymaking experience, (b) ability to run
complex organizations, and (c) strong communication and advocacy skills.
All of these characteristics, then, are technical-managerial. While
such skills are important, they are dramatically insufficient as
requirements for a WHO Director-General. Far more important is what
type of experience does the candidate have, with what type of health
services? And what type of advocacy has the candidate shown, for what
type of health policies? It is surprising that the Lancet, the most
progressive medical journal in the English-speaking world, does not
touch on these issues at all. Julio Frenk may indeed be very
experienced in managing a voluntary health insurance system, and very
skillful (if somewhat unethical) in advocating insurance-based managed
care systems and policies; but such systems and policies have proved
harmful in both developed and developing countries. Moreover, health
depends not only, and not primarily, on medical care but on political,
economic, and social interventions. The evidence for this is well
established, robust, and overwhelming (19), so it would be appropriate
to evaluate a candidate's awareness of this reality. Again, Frenk's
government (the Fox administration) has developed economic, political,
and social public interventions that have significantly increased
social and health inequalities in Mexico. Furthermore, as the highly
respected Economic Policy Institute in Washington, D.C., has shown
(20), Fox's active support for NAFTA (North American Free Trade
Agreement) policies has adversely affected the working conditions of
Mexican workers. Most new jobs created during Fox's tenure do not
include health benefits coverage. And Julio Frenk supported these
Evidence of the impact of economic and social inequalities on
people's health and quality of life is extremely well documented (21).
And there is also evidence that political forces committed to a
redistribution of resources are more successful in improving the
health of populations than political forces not primarily concerned
with redistribution (22). Right-wing governments such as Fox's liberal
government are not known for their concern about redistribution of
resources. Quite to the contrary. Frenk and Fox are at one extreme of
the political spectrum in Latin America, and in the world. If one
extreme is excluded because it is too far left, how can it be
acceptable that a person at the far right is the "reasonable" and
leading candidate for WHO Director-General?
The appointment of Frenk to the leadership of the WHO would follow
the pattern of appointing Rodrigo Rato – Spain's Minister of Economy
in the right-wing government of Jose Aznar, close friend of Bush – as
head of the IMF, and appointing Paul Wolfowitz – close advisor to Bush
– as director of the World Bank (23). This appointment would be wrong.
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