Public healthcare workers march in Athens against cuts. Demotix/Nicolas Koutsokostas. All rights reserved.Last month, more than 15,000 people in 64 countries joined the first Global Day of Action for the Right to Health. The day, coordinated by a new group called Article 25 (after the UN declaration of the right to health) brought people together for more than 165 events around the world.
As it turned out, no individual march or rally was particularly large. The biggest gathering was at a candlelight vigil in Kathmandu of a little over a thousand people. Most events were much smaller: groups of 50 or 100 people gathering together in a city square in Calicut or a park in Chicago. On the scale of movements such as the Arab Spring or protests such as the recent People’s Climate March these numbers are a blip on the screen.
Then why does this matter?
A storm of maladies
Together these events represented the humble start of something potentially much larger: what Article 25 calls a global people’s movement for the right to health. A storm of maladies makes this particularly timely. In the foreground, the crisis of Ebola has laid bare the consequences of absent health systems in west Africa. Meagre public financing of health, the exploding cost of new drugs, and the rising tide of chronic illnesses cause the everyday catastrophes that patients and caregivers face from west Africa to rural India to communities across America.
The conventional wisdom is that these challenges will be solved by experts at global and local agencies. A belief in technocracy harkens all the way back to Plato, who, suspicious of the masses, believed that an elite group of leaders trained with the right makeup of judgement and intelligence should be entrusted to make decisions for society.
To be sure, technical strategies are crucial for the complexities of health, and have led to significant advances in what some have dubbed “the delivery decade”. The dramatic improvements in Rwanda’s health outcomes or the global scale-up of HIV/AIDS treatment, for example, would not have been possible without the work of experts in a variety of areas ranging from drug development to health-delivery science.
But these technical approaches can rarely be neatly divorced from citizens, who possess multiple powers: from imagining alternative possibilities that challenge experts and institutions, to sparking social change in areas blind to society’s leaders, to expressing the expert knowledge of their own experiences of health, illness, and their bodies.
To mobilize this power, however, citizens need options that Plato would likely have been unwilling to offer.
In 1970, the economist Albert Hirschman published his classic work Exit, Voice, and Loyalty on the possible social response options to poorly performing organizations and institutions. Hirschman described two primary responses. He defined “voice” as speaking up and trying to remedy the situation and “exit” as leaving without trying to fix things. Another response, “loyalty”, translated to exercising voice over time by staying in an existing relationship or system. His simple framework gained popularity for its ability to describe wide-ranging political and social phenomena.
Taking Hirschman’s view, the choice between “voice” and “exit” had significant consequences for the relationship between citizens and government and other powerful actors. Those who could afford to "exit" were often those with the most wealth and power to change the system in the first place. Imagine, for example, wealthier parents enrolling their children in private schools instead of the underfunded local public school. Or the allure of unregulated, privatized health care where public provision is deemed inefficient.
For those with the least material wealth, however, exiting is not a ready-made option. This is especially true when it comes to health and health care. In those situations, “voice” is an essential ingredient for change.
Voice is no panacea, but when linked to concrete programmes of action, it can provoke change in the political process or lead to new possibilities. Multiple opportunities abound for Article 25 and other movement-based organizations working on health issues.
At a local level, citizens can find avenues to hold institutions accountable and challenge bottlenecks to care by using organizing techniques and digital technologies. Last year, for example, TB activists in India used offline demonstrations and online petitions to raise the alarm on TB drug shortages and spur an emergency response from the Indian government. The Open Society Foundation believes in the promise of this approach, supporting strategies such as social audits and community scorecards.
At a global level, campaigns may transform norms and policies that cross borders. Linking citizens together from around the world has in the past expanded the horizon of what is possible: the HIV/AIDS movement, for example, played a critical role in scaling-up access to treatment for millions in the late 1990s and early 2000s. A similar strategy will help to make new medicines affordable to patients, address non-communicable illnesses from cancer to diabetes, eliminate user fees, and build universal health systems.
Finally, these approaches make voices – and more of them – matter at a time when exit is the tacitly acceptable option. In this view, citizens are active shapers of their futures rather than passive recipients of status quo policies. By linking voice to specific goals, this vision can breathe with possibility.
We might read the Day of Action, then, as a challenge on two fronts: both to the institutions responsible for health as well as the potency of public voice. Article 25 should pay heed to 350.org, which, along with its allies, has placed climate change action squarely into the lives of political leaders and citizens around the world. Hirschman, a subtle thinker and unconventional economist, would be proud of the inheritors of his ideas.