The history of global health and of the World Health Organization (WHO) is often told by the few voices that are in positions of command. However, the multilateral historical perspective and research in human sciences can contribute with new discoveries that challenge the idea that global health decisions are taken by a handful of actors from dominant countries. This is the proposal of the researcher of the University of York and head of WHO Collaborating Center on Global Health History, Sanjoy Bhattacharya, who was at Fiocruz for the 135th Global Health History Seminar, with the theme Primary Healthcare in historical and political perspectives.
Photo: Peter Ilicciev
The seminar was held on 25 September at the Conference Hall of the Center of Documentation and History of Health (CDHS) at Casa de Oswaldo Cruz (COC/Fiocruz). In addition to Sanjoy Bhattacharya, the event was also attended by the researcher of the Sérgio Arouca National School of Public Health (Ensp/Fiocruz) and coordinator of the Zika Network of Social Sciences, Gustavo Motta, and the COC/Fiocruz professor and publisher of the História, Ciência, Saúde (History, Science, Health) - Manguinhos magazine, Marcos Cueto, as mediator.
Decolonizing the history of WHO
“The history of global health is very important because it shows us the multiple voices that were present when policies were made, not only at WHO’s headquarter level, but also in regional offices and in all member-states, where health policies are implemented”, explained the researcher from the University of York, who has a study on the control of smallpox in India.
Sanjoy Bhattacharya defends research in other languages other than the official UN ones, in order to have a more complete view of the history of WHO. “We need to build a history of WHO from the bottom up”, he argues, highlighting the importance of looking at what countries not considered protagonists were proposing.
The head of the WHO Collaborating Center recalls how, at the historical moment when WHO was created, right after World War II, important political processes were taking place all over the world, such as the fight for independence in Asian and African colonies. The fight of former colonies has had a strong influence on important achievements, such as acknowledging Primary Healthcare as a priority during the Alma-Ata Conference in 1978.
The historian draws attention to the composition of the first WHO Executive Committee, which had representatives of countries such as Brazil, Egypt, India, Mexico and Iran. “What were these countries doing and proposing there?”, he asks. “I like asking inconvenient questions.”
“When we focus only on WHO headquarters, we often forget that there are many local factors involved in the implementation of policies and programs: preparation for research, preparation for analysis and preparation for implementation”, the researcher explained.
For him, the decision-making and implementation process in WHO can be described as “a complex and horizontal mosaic of thoughts, negotiations and actions”.
“When we study the critical history of health research, what we manage to do is to find local examples. Examples of success in the production of data, community involvement and analysis and, first and foremost, examples of successful community cooperation in implementation”, he states.
Challenges for Primary Healthcare
Fiocruz researcher Gustavo Matta presented next some of the main challenges that the idea of primary healthcare faces today. Among them, Matta highlighted financing, tensions between public and private interests, and the issue of inequities in countries and between countries. For him, these tensions pose questions that are hard to be answered, but that need to be faced in order to ensure health as a human right.
According to the sociologist, the manner in which health figures are produced and presented by reports and maps of international organs and agencies can make it difficult to understand the problems. “The reports by WHO and other agencies often use simplistic definitions that hide inequities”, he states. One example, according to Matta, is the World Health Report of 2006, which includes a map with the countries where health workers are scarce. The map, however, fails to look into the inequalities within the countries and reduces an important problem - access to healthcare - to a single indicator.
For the coordinator of the Zika Network, when we look at the global health scenario and at the discussion on primary healthcare today, we should look beyond WHO. The financing agencies are in charge of a good part of the budget for the programs. In addition, the great pharmaceutical industries also play an important role in this context, as their economic interests interfere directly on the availability of medical drugs.
As primary healthcare is one of the main policies under debate in the health sector, Matta agrees with the document produced by Fiocruz researchers and presented during the Global Conference on Primary Healthcare that took place in Nur-Sultan (formerly Astana), Kazakhstan, last year. The text considers that primary healthcare cannot be the equivalent of a reductionist proposal of universal health coverage, or it may restrict the possibilities of guaranteeing the human right for health.
Mediator Marcos Cueto enriched the debate with a brief history of the proposal of Universal Health Coverage, which has just been approved as a global goal by the UN General Assembly. “The idea of universal coverage arose between 2003 and 2006, when WHO had a South Korean director, Jong-Wook Lee. He considered that universal coverage was a proposal that would be accompanied by other important measures, such as a discussion on the social determinants of health”, Cueto explained.
The COC researcher said that during his mandate, interrupted by his death, Lee took a series of actions, such as the creation of the Commission on Social Determinants, the launching of important reports, and the creation of a policy for access to anti-AIDS drugs. “This policy was backed by the idea that public health was a public asset, not goods to be traded, as it is defined by many of those who advocates for privatization”, he said.
For Cueto, the next WHO director after Lee’s death, Margaret Chan, was not particularly interested in this holistic view of universal coverage. In addition, the 2008 economic crisis affected the more extense proposals. “I believe that after 2018 some agencies have beginning to see universal health coverage as an even more narrow issue. They have forgotten this proposal that Lee had made of a more integrated, holistic idea, when he was WHO director, and left behind the principles of Primary Healthcare and Universal Health Access that is defended by countries such as Brazil”, he affirms.
With the approval of the proposal of Universal Coverage as a goal for countries and a priority for WHO, Cueto believes that the debate is now in a different moment. “The dilema now is: in this fight for health as a right for everyone, should we make an alliance with those that advocates for universal coverage or should we adopt a more critical posture?”, he asks.
Global Health Histories Seminars
This was the 135th Seminar on Global Health Histories, organized by the WHO Collaborating Center for Global Health Histories. The seminars have taken place since 2005, each issue at a different location, and attempt to bring a critical view of the history of global health. This edition was organized by a collaboration between the Zika Network of Social Sciences, the Casa de Oswaldo Cruz, the University of York, the WHO Collaborating Center on Global Health History, and Wellcome.