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LATIN AMERICA
Regaining the right to health: preliminary lessons from a work in progress
Eduardo Cáceres Valdivia*
4/23/2015
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The history of rights in Latin America and the Caribbean is not a simple story. While rights are, by definition, inherent to humans, their recognition and enforcement depends on social and political correlations that change throughout history.

A good example of this are the vicissitudes of the social, economic, cultural and environmental rights, particularly the right to health in our continent. Demands related to health appear very early on in the platforms of workers´ movements, whether in countries that initiated industrialization early on (Mexico, Argentina, Brazil) or countries that were the seat of mining enclaves (Peru, Bolivia) and agro exporters (Colombia, Central America and the Caribbean). At the same time, the literature of reports about the conditions of indigenous peoples also included references to the serious health problems associated with rural poverty.

It was not just the accumulation of complaints and reports that created a space for health in the emerging rights agenda. Cultural changes were added to the social mobilizations. First came the renunciation of a “providential” view of health. Advances in science helped put in the hands of people the possibility to not only to be cured but also to prevent disease. Second, medical and social sciences came together to bring the analysis of socio-economic determinants of health to the forefront. The interest in disease moved to the interest in public health.

Without going too much into the details of the History, the first half of the 20th century was the scene of the creation of a Latin American vision on the right to health as outlined in Article 11 of the American Declaration of the Rights and Duties of Man: Every person has the right to the preservation of his health through sanitary and social measures relating to food, clothing, housing and medical care, to the extent permitted by public and community resources. The first lines give a good overview of the broad vision of health, while the latter mention the unresolved issue of public health funding.

Constitutions and laws
While the right to health is mentioned in all the constitutions of the region,1 the practical recognition of it varies significantly. There are, however, some similarities. For example, the most organized sectors of society tend to have their own health care systems funded by direct contributions (as in the case of Social Security for formal employees in most countries). Additionally, even within this group there are sectors that have special systems (those in the petroleum sector in Mexico and other countries, the armed forces in all countries). Yet, most people have to solve their health problems in public hospitals and public health posts, in a system that was never “free”. The situation has been particularly serious for rural and indigenous populations, including those countries that have had some form of agrarian reform (Mexico, Bolivia, Peru).

In the context of inconsistent laws and constitutions, in practice the execution of the right to health has depended on the balance of power in each country and in each situation. Except in exceptional moments, the relationship between pro-health social movements and the academic-professional pro-health reform movement has been weak, if not non-existent. As a result, by 1980 serious structural problems built up in health systems of most countries in the region: lack of coordination and cooperation between various parts of the health system, significant disparities in the quality of the services provided, excessive administrative costs, lack of coverage in rural areas, and corruption in management.

When the economic crisis joined the aforementioned list of issues, a solution to the resulting crisis within the health system could be found neither from the social movements nor from academic and professional sectors. In a highly fragmented system, full of little “privileges”, the most common response was to defend specific agendas. The unions of insured workers, doctors and other health workers, and officials and administrators responded to the crisis by holding on to their specific demands. They did not take into account that — in most cases — the society as a whole was not part of the conflict.

The assault on public health: the lost decade
The term “lost decade” is used to refer to the years (mid 80s to late 90s) after the debt crisis when neoliberal reforms began to be implemented. Far from promoting growth, these policies made societies pay the cost of fiscal adjustment.

In the field of healthcare — as in the field of education — the “lost decade” caused a particularly bad outcome. The crisis and fiscal adjustment led to the collapse of public and social institutions as these became demoralized and underfunded. This process was also accompanied by a media blitz regarding the ineffectiveness and inefficiency of the state and its institutions. This was the perfect prelude for downsizing the state and privatizing institutions. It is no coincidence that the most systematic approach to reforming the health sector came not from organizations such as the Pan American Health Organization (PAHO) and the World Health Organization (WHO), but from the World Bank.2

The key points of the reform can be summarized in three words: targeting, decentralization and privatization. Assuming that health is the “private” matter of  individuals, it is left at the hands of people to choose the system they deem appropriate. The state has to only take care of the poor (targeting) and regulate competition between various health providers. As a general rule, the provision and financing of each service (whether through the private sector or what remains of the public sector) is subject to a cost/benefit analysis.3 One result of the application of this new approach was the definition of a “basic health services basket” that the state should guarantee to those who could not fend for themselves in the healthcare sector. This is certainly a segregationist perspective that is at odds with a view of rights.

Two decades — or more — after the fiscal adjustment and neoliberal reforms, it is not difficult to conclude that their impact has been rather negative, particularly in healthcare. More important than going into the details of the failures, we have to ask how this could be implemented. Not that there was no resistance; on the contrary, in all countries there were protests coming from the various sectors affected by the reform, including the healthcare workers themselves. The main limitation for these resistance movements was — and is — that their scope was limited to unions and sectors. For significant sections of the population, the alleged “universal” nature of the previous systems was chimerical, while the new “basic health services basket” is a tangible reality. In most countries there was not a citizen movement for the right to health. At best, there were some forums and discussions that were no more than critical analyses of neoliberal reform and its impacts.

New movements and “reforms” within the reform
A novelty in the last decade has been the emergence of a new stakeholder: the citizen who uses health services. On one hand, this stakeholder is a limitedly recognized figure within neoliberal reform (the “citizen-customer” may in principle complain to the supervisory bodies regarding quality and opportunity of the service rendered); on the other hand, we are talking about a specific version of a stakeholder who has gained visibility in various fields in Latin America: the citizen who holds rights.

Increasing the legitimacy granted by the reform, the citizen rights holder goes beyond the vendor/client relationship and demands the very definition of the services rendered. Furthermore, this type of citizen does not demand only, but act together. As a result of this dynamic, we have seen across the continent the emergence of movements of patients and of people affected by any disease or environmental damages that affect health. The pioneers in this have been the movement of people living with HIV/AIDS who have been key in the creation and implementation of public policies aimed towards their demands.

The new citizen movements in the health sector have successfully used the strategies of the human rights movement. These strategies include, among others, the so-called “strategic litigation”, or taking symbolic cases to national and international courts in hopes of not only obtaining a solution for the specific case but also to influence global public policies.4

The answer did not take long to arrive: in most countries, there are ongoing “reforms” within the neoliberal reform, which are aimed at trying to reduce inequalities, expand coverage, and improve quality without compromising the foundations of the current model.5 The possibilities of success for these reforms are to be seen; however, they create a new opportunity for the discussion of the right to health and public health as a core responsibility of the state.

An alternative path
The story concisely described above has some exceptions, however. One of the most notable exemptions is Brazil. Brazil was able to transition from a constitutional principle (Article 196 of the Constitution of 1988) to a Unified Health System (SUS) due to the presence of the “Movement for Public Health”, which represented the coalition of a large portion of civil society. A privileged scenario for that joint forces have been the National Health Conferences. The first Conference was held in 1941 and the most recent (the 14th) in 2011.6

While the first conference had agendas limited to health problems, starting in the fourth conference (1967), references to socio-economic factors were introduced with a heavy emphasis. The eighth conference (1986) was a huge milestone. It was the first one that involved sectors of civil society beyond those directly involved in the health sector. There were more than 4,000 delegates in total, led by members — mostly professionals — from the “health movement”. From this event emerged proposals for the Constituent Assembly of 1988. Since then to today, the National Conferences’ main task is to contribute and strengthen the SUS.

The lesson of this experience is clear: only broad coalitions of social and citizen movements can ensure recognition and full enforcement of human rights. When these partnerships do not occur, fragmentation and disagreements become the allies of proposals to privatize and deregulate social life.

*Bachelor of Arts in Humanities with major in Philosophy, from the Pontificia Universidad Católica del Perú. Has been part of organizations linked to popular education and human rights. He has developed research on social movements, analyzing power and inequality in Latin America and the Caribbean. Member of the Asociación Pro Derechos Humanos  (APRODEH) of Peru.
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1 Pan American Health Organization and World Health Organization, The Right to Health in the Americas: A Comparative Constitutional Study, Washington, 1989.
2 World Bank, “World Development Report 1993. Investing in Health.” Washington, 1993.
3 For this a new tool was introduced:  "Disability-adjusted life year" (DALY) that calculates the “value” of the life of the person requiring a specific treatment. For a discussion of this: De Currea-Lugo, Víctor, "La encrucijada del derecho a la salud en América Latina," en Yamin, Alicia Ely (coordinator) Los derechos económicos, sociales y culturales en América Latina.  IDRC -APRODEH-Plaza y Valdés Editores. Mexico, 2006, pp. 215-234.
4 Reveiz L, Chapman E, Torres R, Fitzgerald JF, Mendoza A, Bolis M, et al. “Litigios por derecho a la salud en tres países de América Latina: revisión sistemática de la literatura.” Revista Panamericana de la Salud Pública, 2013; 33 (3): 213-22.
5 Popular Health Insurance in Mexico, Comprehensive Health Insurance in Peru, Universal Access with Explicit Guarantees in Chile, etc. A recent World Bank study on universal health coverage includes eight case studies of Latin American countries. Available at:
http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/0,,contentMDK:23352920~pagePK:210058~piPK:210062~theSitePK:282511,00.html
6 Between 1988 and today there have been more than 90 conferences that covered 33 topics.  A national conference usually takes a year from its announcement to the end of the final meeting. Between conferences there is a National Council that tracks agreements, public policies and their outcomes.


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Citizens increasingly continue to demand the state for their right to quality health services. /Telesur
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