Now that we have learned how difficult, and misguided, it can be to try to spread democracy throughout the rest of the world, we may be better able to spread some here.
The need to refocus our resources and energies at home has raised health care to prominence once again, and that is surely a good place to start. Democratizing the delivery of health care was once before made a national goal when it was implicit in the community health planning promulgated by the National Health Planning and Resource Development Act of 1974, the first and last Public Law passed to facilitate a national health planning policy. At that time, it was seen as good government – stewardship of publicly owned resources that was best carried out by involving ordinary citizens in their own communities to participate in making some of the key decisions about health care delivery. It was also good planning in that it was planning with communities, not just for them. The willingness of government to collaborate with communities sent a powerful message to everyone, one that strengthened democracy. The lesson it seems we need now to relearn is that democracy is about equity, and equity cannot be given to communities, it must be developed out of their own engagement in equitable processes of decision making.
Any national health care system that would serve the best interests of its constituents for greater equity in health must have health promotion through primary care as its fundamental priority. The full benefits of primary care require social justice with community participation and empowerment, and that was precisely the health policy ratified by WHO member states in the Declaration of Alma-Ata in 1978. The fourth article of the Declaration stated that, "people have the right and duty to participate individually and collectively in the planning and implementation of their health care," and the seventh article stated that primary health care "requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care." In 2000, the UN Committee on Economic, Social, and Cultural Rights, working in close collaboration with WHO and many others, drafted and adopted general comment 14 that requires health systems to include institutional arrangements for active and informed participation in strategy development, policy making, implementation, and accountability by all relevant stakeholders, including disadvantaged individuals, communities, and populations. General comment 14 stands as the world’s most authoritative operational understanding of what constitutes a right to health.
Knowledge Is Power
The role of government is to ensure the conditions in which people are able and encouraged to work in association with each other to produce the society that best suits them. Communities are entitled to the right to identify and frame those issues that most concern them, and to advocate for solutions satisfactory to them. Health is a special dimension, for while communities hold the key to the conditions for health, health itself is a property of individuals. Recognition is given to this when the aim of medicine is seen to be that of informing the judgment of its autonomous patients in making decisions that guide their care. For government health planning, the community is the patient served by public health, but the ultimate beneficiaries are still autonomous individuals whose judgment about conditions of health must be informed as well as respected. A government that respects its constituents solicits their opinions and judgments.
At the policy level, accountability for health and for all the disparate influences that threaten it may be shared by giving the public a formal role in decision making about health system priorities and resource allocation. What is thus being shared is information, and information empowers people when it gives them real control over the decisions that affect their lives. This is the essence of democracy, and it requires that private plans be made public information in a process that encourages civic discourse and deliberation on their merits. In this manner, accountability for access, quality, and safety is shared between the public and the government, the patient and the provider, at all levels in the total healthcare delivery system.
Empowerment of people by their government is a prerequisite for social justice. Government agencies must share their information and decision making power with communities and respect public opinion. When government planning becomes community planning, there is greater accountability for the appropriateness of that planning. Seen as appropriate, the plans can be expected to foster public support for greater funding of public health.
Despite the vigorous national debate on "health care reform" that has been a constant for the last two years, no presidential candidate, and no subsequent political initiatives, have addressed how reform might encourage the people themselves to take part in shaping health care planning and implementation. The promise of "health care reform" must be to give us a just system of health care, and that cannot be accomplished in a democracy without its constituents seeing that they have a stake in how it works in their communities. Perhaps the Institute of Medicine Committee on Assuring the Health of the Public in the 21st Century said it best: "Realizing the vision of healthy people in healthy communities is possible only if the community, in its full cultural, social, and economic diversity, is an authentic partner in changing the conditions for health."
By John Steen, jwsteen@zoominternet.net
* A full-length version of this essay, along with references and citations, is available.