All Health Is Public Health

For decades, we have been sold a myth of private health. It is a myth that our health is largely a product of individual choices and personal responsibilities. It is a myth that our healthcare is a service that private corporations can provide, and for which we must pay to survive.

But the COVID-19 pandemic has blown up this myth.

Our personal health cannot be separated from the health of our neighbors or our planet. Nor can it be separated from the structural factors and policy decisions that have determined our health outcomes long before we are born.

The right to health, in the context of these interconnections, is a universal right. Your life is worth no more and no less than that of your next-door neighbor because the fates of the two are so intimately entwined.

"Any strategy to reclaim public health for the public good must center social determinants and seek to increase public power across sectors of the economy responsible for the basic conditions of human life and the stability of our environment."

Today, the universal right to health is not held back by scarcity of resources or a lack of technology. On the contrary, the wealth of this world--invested well--could end the pandemic before the year's end.

Instead, we are held back by another myth: that there exists a trade-off between public health and the health of the economy. The assumption of this trade-off dictates that all public policy is subordinate to the great god of economic growth--even if it costs us our lives. The concept of private health grows out of this second myth, which makes a commodity of our bodies, and a market for essential healthcare services.

Indeed, public health systems around the world are structured carefully to serve a profit motive. Unsurprisingly, their outcomes are inequitable and insufficient, leaving poor and marginalized communities with no recourse to private health provision.

Drawing on the evidence of health impacts of the coronavirus pandemic and the impact of policy responses, the racial, gender and class dimension in the impact of the virus is undeniable. The raw reality of systemic fragility of both public health and economic systems in the North in dealing with the social crisis has also been brought to the fore. Those countries that have been successful--such as Vietnam, Cuba and New Zealand--viewed public health as economic wealth.

Once again, we return to the basic premise. Health, in all its dimensions, is a public good.

How can we deliver a world that reflects this simple premise?

The first step is decolonization. Countries in the Global South cannot deliver on the promise of public health when they are curtailed by neocolonial conditionalities that come along with philanthropic funding and multilateral lending. This top-down approach strips countries of their sovereignty over how to fund health services, privatizes health infrastructure and cripples social policy provisions.

Most of these countries assured universal health services as a matter of course in the 1960s and 1970s. Then came structural adjustment. The imposition of the Washington Consensus in the course of the 1980s and 1990s led to a radical reframing of the health sector as a profitable site of privatization and deregulation. The introduction of user fees and prioritization of imported, high tech-fixes forced millions of poor people to the margins, as "private health" became the norm. Provision in the form of "minimum packages" took priority over comprehensive primary and community health.

Public health, then, requires public ownership--a form of ownership that can deliver transparency and foster citizen participation in the delivery of healthcare services. Public sector clinics, homecare companies, and biomedical enterprises should be built to assure the production and distribution of essential medicines and medical technologies as well as healthcare services.

Free from the structural constraints of shareholder primacy and profit maximization, these enterprises will be able to prioritize preventative and curative technologies, fill gaps in existing treatments, and provide products at or below cost where necessary to meet public health needs.

Moreover, they can return revenue to public balance sheets, reduce inefficiencies, and create surge capacity for emergencies. Having a robust public sector infrastructure for the development, manufacture, and distribution of essential goods like medicines, personal protective equipment, and other medical instruments breaks the corporate monopoly over our supply of medical goods, reducing regulatory capture and increasing public power to demand equitable and universal access to critical health goods and services.

Health as a public good offers positive externalities for the economy and society. Even if we just follow the logic of narrow economic growth, a dollar investment in health in developing countries is estimated to result in between $2 and $4 in economic returns over time. And those dollars are best spent when communities and nations have the autonomy to prioritize their own needs and invest in long-term institution-building that will serve their communities for years to come.

Countries like Cuba and Vietnam have demonstrated that, even with modest budgets, developing a sovereign healthcare system that prioritizes primary and preventative care together with robust public health infrastructure can deliver first-rate population health outcomes. [Investing in public healthcare systems has been shown to contribute to better outcomes] than investing in privatized healthcare systems. Freeing the healthcare sector from market imperatives would allow for the recentering of primary and preventative care, planning for equitable access, and robust community health outreach--not traditionally the profit-making parts of healthcare delivery. Additionally, targeted workforce development programs can be created to meet community needs while providing stable, public sector jobs that are themselves an upstream investment in community health.

Reclaiming autonomy of the public sector by sovereign nations requires a shift from the current donor-driven vertical disease control programs most funded in prioritizing the needs of the community. Vertical interventions to eradicate single diseases are often costly and have been imposed on low and middle-income countries at the expense of horizontal enhancements of public health infrastructure that would serve whole populations over the long term and make local health systems more resilient. They also contribute to internal brain drain with skilled people leaving the public sector to work for higher pay in international and nongovernmental organizations.
"The COVID-19 pandemic has opened a window of opportunity to revisit and reevaluate the many myths that held up a broken system of global health. And in doing so, it has offered us the chance to deliver a truly global public health system: equitable, inclusive and people-centered."

Reversal of structural adjustment conditions and untying loans, donor grants and external funding from conditionalities is essential in reclaiming sovereignty in the national public health decision space. Complete restructuring of the global health governance mechanisms to ensure democratic representation in decision-making by every participating country, whether they are net donors or net recipients, is vital. Global health governance mechanisms must have measures in place to ensure that external influence exerted over countries is subordinate to national sovereignty, and that the activities of global health organizations without a democratic mandate are overseen and their impact held to account by national governments.

Representation of the most marginalized and communities most impacted by colonialism and structural adjustment on governance of global health and financial institutions is important for their priorities and perspectives to be included on the agenda and in development priorities. In addition, more community empowerment, participation, and co-planning in the process of deprivatization of healthcare services can aid in the democratization of healthcare and provide increased opportunities for transparency, citizen accountability, and oversight.

Hand-in-hand with the reclaiming of the healthcare sector for the public good should be the reclamation of essential services like water and power. Investments in public power and water--coupled with divestments from fossil fuels--would build both climate resilience and more equitable access to the basic infrastructure of public health. Amongst the greatest challenges to public health in many countries around the world are still infectious diseases like tuberculosis, malaria, and lower respiratory infections, all of which correlate highly to social determinants like access to clean water and good living conditions, air quality, and sanitation. Any strategy to reclaim public health for the public good must center social determinants and seek to increase public power across sectors of the economy responsible for the basic conditions of human life and the stability of our environment.

The COVID-19 pandemic has opened a window of opportunity to revisit and reevaluate the many myths that held up a broken system of global health. And in doing so, it has offered us the chance to deliver a truly global public health system: equitable, inclusive and people-centered.

A withering critique of capitalism is not enough. It is time to reimagine a world where human life and environmental sustainability are the first priority, and where that universal right to health is the basis for all public policy.

A system premised on this universal right--and powered by global solidarity--is not only possible. For our species to survive, it is necessary.