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People over profit: a critical paradigm shift to realize health for all

By guest contributors Leigh Kamore Haynes, Ravi Ram, Shweta Marathe, and Matheus Falçao

As the world looks toward the other side of the COVID-19 pandemic, there is a clear opportunity to re-examine the systemic issues that underlie – or undermine – global health, including health equity, social justice and decolonization of health systems. A key driver for the sustained gaps in health equity and social justice is the privatization and commercialization of health, both in its financing and delivery of services. The right to health has been deliberately side-lined, even when those rights are codified in national constitutions.  

In response to the continued threat of degradation of health systems due to privatization and commercialization of health services, health activists around the world have united on World Health Day (April 7) to amplify the call for strengthened public health systems that are patient- and worker-centered, reflect a fair distribution of resources, and challenge colonial narratives of decision making and power.  

The problem of privatization: Health for sale

Governments and international institutions consistently engage the private sector in efforts to build and strengthen health systems. The prevailing rationale is that the private sector can provide improved access, efficiency, and quality. However, after nearly half a century of this approach, evidence from around the world shows the opposite. Philanthrocapitalists, corporations, development banks and private financial firms, which hold unaccountable power, have shaped health financing policy to serve their interests. They have benefited heavily from the notion that health is a commodity and not a right, subjugating action on the broader determinants of health.

In India, pro-privatization policies dating back to the 1990s led to the country’s burgeoning private healthcare sector, which has failed to deliver on India’s UHC goals. Currently, 70% of all patients are treated in the private sector and 70% of the entire health workforce serve in the private sector. The cost of hospitalization is six times more expensive in private hospitals than in public hospitals, even as the government receives numerous complaints about malpractice in those private clinical establishments. Meanwhile, the national public health system has gone underfunded (only 1.2% of the country’s GDP funds health, much lower than the global average of 5%), resulting in overstretched public health facilities. Yet, the private sector in India remains poorly regulated and major health insurance schemes launched under the guise of Universal Health Coverage (UHC) ignore critical evidence and rely on private hospitals.

Brazil’s Unified Health System (SUS)–formal acknowledgement of the country’s constitutional Right to Health–is one of the largest public universal access health systems in the world, covering a population of 220 million. Although every person living in Brazil is entitled to free healthcare, health spending data reflects a dual system that has emerged in the face of private sector engagement. Of the 9.6% of total GDP spent on health, only 3.8% goes to the SUS. The majority of spending goes towards private health insurance, which covers about 25% of the population, and out-of-pocket spending, especially on medicines. The SUS suffers from underfunding, a lack of strong workforce policies and increasing costs. Although underfunded, the public system achieves much more than market-driven healthcare. Despite the SUS’s achievements–even heralded by the World Bank– commercialization in health has accelerated. In particular, the outsourcing of public system management to the private sector through Social Health Organizations decreases public control over the system, creates fragmentation and shows no advantage over the public model.

Kenya has seen a similar impact of the private sector siphoning funds and health workers from the public sector. The country’s UHC program is run by the National Hospital Insurance Fund, a parastatal organization, and funded by a voluntary subscription model. Under this model, heads of households must regularly pay a monthly fee for coverage; a lapse in payment results in a 60-day suspension of health coverage even after subscription resumes. Moreover, public health services in Kenya remain burdened by shortages of health workers and medicines meaning patients must seek care at private treatment centers. Private care providers have negotiated higher reimbursement rates for the UHC basket of services, thereby turning UHC into a profitable siphon of funds extracted from the general public. Moreover, services covered under UHC focus on treatment, ignoring the broader spectrum of PHC including health promotion and disease prevention, as those are not readily commercialized. Nevertheless, Kenya’s new government has expressed an interest in expanding private sector involvement in health and other public sectors through the World Bank model.

Even in countries with robust health systems and resources for health, such as in many European countries, privatization and commercial practices constrain access to healthcare and, particularly in the hospital sector, more profitable patients are prioritized. In the United States, a system dominated by private interests, healthcare spending outpaces the OECD average by nearly 10% yet health outcomes remain some of the worst in the world, with the heavier burden falling on migrants, poor people, and racialized populations.  

Solutions that embody human rights and equity

To achieve true health for all, bold solutions that center human rights and equity are urgently needed.

  • Dismantling the damage caused by the privatization and commercialization of health systems requires that governments center justice and principles of human rights rather than false market logic. Rebuilding equitable health systems calls for a decolonization of the power structures and institutions that determine health nationally and in the global health architecture. 
  • Equity demands social participation in health whereby health policy and associated accountability mechanisms are developed and implemented collectively, with public participation.
  • Meaningful efforts towards financial justice can deliver the financing necessary for strengthened public health systems, typically through established mechanisms such as progressive taxation and redistributive fiscal policies that benefit all of society. 

Health for all 

“Our health–not for sale” is the declaration of many health activists and advocates this year on World Health Day. Privatized, commercialized health care has not delivered on its promises to all people; rather, it has benefitted those who wish to gain from the profits extracted. The current paradigm is, as demonstrated across the globe, harmful to people’s health and detrimental to efforts to achieve health for all. As envisioned in the Santiago Declaration for Public Services, human rights can be secured for everyone when public services are “out of private control, and under decolonial forms of collective, transparent and democratic control” across health and all sectors. 

About the authors:

Leigh Haynes is a lawyer and public health professional whose work and research falls at the intersection of public health and human rights. Haynes’s research and practice centers around the right to health, focusing on the role social movements and people’s organizations play in influencing health policy. Locally and globally, Leigh advocates for health equity and social justice, focusing on social, political, and economic determinants that drive health inequities. She is a longtime health activist and organiser with the People’s Health Movement and is part of the public health faculty of Simmons University. She is on Twitter at @leighkamore

Ravi Ram is a health systems evaluator and activist with the Kampala Initiative and the People’s Health Movement in Nairobi, Kenya. At the Madhira Institute he leads gender-responsive and equity-focused analyses and evaluations of the health sector and policies in sub-Saharan Africa and globally. Ravi is active in several civil society networks, and serves on the board of Health Poverty Action and other progressive institutions. He is on Twitter at @ravimram

Shweta Marathe is a researcher at SATHI, Pune, India. With more than a decade of experience, she undertakes research that actively supports policy advocacy for a better health system. Her research interests focus on the transformations in the private healthcare sector. Currently, she is a fellow of the India-HPSR fellowship-2022.

Matheus Falçao is a researcher at the Health Law Research Center (CEPEDISA) of the Health Law Research Support Center (NAP-DISA/USP) since 2013. He is a doctoral student in human rights with a thesis in the field of global health. He holds a Master in Law from the Faculty of Law of the University of São Paulo and has worked on research projects in partnership with PAHO/WHO. He focuses on health law, health systems and global health.

Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.

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