For a long time, Women in Black has organized activities to commemorate two significant dates in the international feminist antimilitarist women's movement: May 24th, International Day of Women's Action for Peace and Disarmament, and May 28th, International Day for Women's Health and Reproductive Rights. At the end of May 2002, we organized the conference Everything for Peace, Heath, and Knowledge, Nothing for Armament. Conferences with the same name were held in Nis in 2003 and in Belgrade in 2004. During these conferences, we not only addressed issues related to the connection between health and armament, but also the state's responsibility for women's health, the privatization and reform of health services, and the relationships between military expenses, security, and peace. In addition to panel discussions and workshops, we have also organized promotions of our new publications, street performances, and marches as part of the conferences.
In this report, we focus on several talks given during these conferences in 2003 and 2004 that illustrate the character of these gatherings.
SECURITY IS INVESTMENTS IN PEACE AND HEALTH, NOT IN ARMS AND UNIFORMS.
Isabelle Geuskens, IFOR (International Fellowship of Reconciliation) and IPB (International Peace Bureau), Amsterdam:
Motivated by the belief that peace can be created only by adhering to the principles of nonviolence, coexistence, and reconciliation, IFOR started directly after the First World War. In 1997, IFOR began programs aimed at supporting women's peace activities in disassembling militarism, one of the main obstacles to peace.
Particularly after the terrorist attacks in New York on September 11th, 2001, military and political leaders worldwide have come to believe that the military industry can provide sustainable peace and that security and stability can be guaranteed through the use of military force—which justifies the enormous budgets for such purposes. This increasing militarization of the world particularly affects women, but women are, more and more, organizing against it. Activists for peace often risk their own lives by crossing and jumping over religious, ethnic, and state borders to alleviate ethnic conflicts. Even though women have been leading these peace-building processes, their efforts are often ignored.
However, the first resolution of the UN Security Council (Resolution 1325, passed in October 2000) about women, peace, and security acknowledges that peace and security cannot be achieved or developed without the active participation of women. Even though an increasing number of international institutions are becoming aware of the necessity of including a gender perspective in conflict and peace building, a huge gap between ideology and practice, documents and reality, still exists. Therefore, important documents have been signed, but their application is slowed by a lack of material resources and political will.
In the twentieth century, the character of war has changed. At the beginning of the century, around 5 percent of victims of war were civilians and soldiers were mostly of men. At the end of the twentieth century, around 75 percent of victims are civilians and a greater number of women take up arms.
1. THE ROLE OF THE VICTIM IS THE MOST COMMON.
Women are victims of rape and forced pregnancy as instruments of war. Women and children comprise 80 percent of refugees and displaced persons. Women's role as victim is used in propaganda and to justify and produce of violence.
2. THE ROLE OF WOMEN IN THE PREVENTION AND RESOLUTION OF CONFLICTS AND PEACE-BUILDING
A greater number of women are engaged in preventing violence and reconciliation programs. The role of women in peace processes is very complex, reflecting women's complex role in society. Not only do women create peace as activists in women's or mixed-gender civil society organizations, they are the most active in education for peace both through formal education and in the context of the family.
3. WOMEN'S ROLE IN ARMED GROUPS.
In states such as the USA, Russia, Canada, Australia, Israel, Kenya, and Libya, women comprise 10 percent of military personnel, while more than one-third of guerilla groups is comprised of women. The mass production of small arms has enabled the increasing participation of boys and girls in armed conflicts, especially in Colombia, Uganda, and Sierra Leone. Women take part in armed groups either voluntarily, seeking revenge or a profit, or through forced conscription. Female combatants are often not included in demobilization processes after wars end; they are exposed to condemnation, isolation and anger once they return to their communities because they have stepped outside of the traditional female role. It is very important for men and women who took part in armed groups to be reintegrated into society.
4. THE ROLE OF WOMEN AS WARMONGERS.
Some women actively advocate war, actively promote armed violence, and encourage men to wage war. I will give two examples. Women from the Hindu community in India have been encouraging men to attack Muslim women in Gujarat. Condoleezza Rice, the American national security advisor, has actively endorsed and still advocates so-called preventive wars in Afghanistan and Iraq.
JADRANKA MILICEVIC, WOMEN TO WOMEN, SARAJEVO/WOMEN IN BLACK, BELGRADE:
On February 8th, 2004 I sent information about the regional women's initiative ‘Not in Our Name, Not with Our Money’ to 120 NGOs in Bosnia and Herzegovina (BH) and asked them to join the campaign. Only 12 NGOs accepted my invitation. What does that mean in light of the fact that there are 8,450 NGOs registered with the Ministry of Justice?
I will illustrate the actual situation in BH with several more examples:
- BH has sent its soldiers to join the occupying forces in Iraq. The state's presidency explained this action with the words "It is about the landmine-clearing units and we in Bosnia know how big a problem mines can be!" It would be interesting to ask them how they would react if, in the middle of 1993 when Serbian forces were occupying more than two-thirds of BH, President Lukasenko of Belarus had sent a “humanitarian” unit of soldier to clear mines under the command of Ratko Mladic (High Commander of the armed forces of Republika Srpska).
- The government leaders of BH have a completely submissive attitude towards the crazy foreign affairs adventures of the Bush administration. For example, BH has signed, in spite of EU opposition, a bilateral agreement with the USA that excepts American citizens from being tried before International Criminal Court (ICC). The BH Presidency justified their stance because of "the need to preserve the American military presence in BH" and fear of possible American sanctions if they do not sign the agreement. However, let us look at the consequences in other countries. Croatia has refused to sign the agreement and there have not been any sanctions. Furthermore, NATO and American soldiers are already planning to leave BH at the end of 2004 and will be replaced with EU military forces.
- Huge funds are spent on representation and traveling: in 2003, just two representatives of the BH Ministry of Foreign Affairs (Mladen Ivanic and Lidija Topic) spent over 200,000 KM (100,000 euro) on this purpose!
- The army is divided on the basis of ethnicity and entity; the military budget is a secret. Military service in the Bosnian Federation lasts four months and civil service lasts six months. In the other entity, Republika Srpska, military service lasts six months and civil service lasts 12 months. Because of these drastic differences, it is necessary to pass a unifying law. Regardless of the fact that BH supposedly has a unified military command (consisting of one Serb, one Bosniak and one Croat), the army is divided. Despite many attempts, we have not been successful in obtaining information about the distribution and size of the military budget.
RUZA CIRKOVIC, BELGRADE, JOURNAL1ST FOR THE WEEKLY NEWSPAPER NIN:
As far as the relationship between military expenses and the economy is concerned, research results are lacking and controversial, especially on the global level.
If we observe conditions on the level of individual countries, the results are controversial as well. After World War Two, Germany and Japan experienced a great economic boom. They were the countries whose investment in the army were drastically limited as part of the terms that ended the war. Because they did not invest in the military, they could experience their economic boom. It can be concluded that there is no positive relationship between military investment and economic growth, without even factoring into the equation the large number of human victims and the destruction of material goods that occurs through military investment.
It is very hard to conduct that analysis here, because as in other countries, military investment is secretive, and there is always the suspicion that there exists a secret fund as well. A few days ago, the government of Serbia and Montenegro adopted a regulation about a fund for the reform of the army outside of the budget: it has been explained that the fund will be filled as the army productively uses or sells its property obtained in recent decades. By its political position in the world and by what it has experienced in the past ten years, Serbia cannot decide alone about military expenses. Serbia is economically ruined; during the last decade, state revenue has decreased by more than half. Because of this, investment in the army had to fall, even though the military budget consumed 70 percent of the federal budget for years.
In addition, Serbia has been politically ruined and its obligations under the Dayton agreement has required that it drastically reduce its armament and army. Even after the regime change on October 5th, 2000, the international financial institutions requested that Serbia reduce its expenditures. Therefore, not as much is invested in the army as was previously. Here is an example: before 1991, the army took journalists to Karadjordjevo (an elite military recreation facility) to help the army lobby to obtain a two million dollar budget for buying breeding horses. Now, the army takes journalists to meetings in which they complain about the more than 20,000 military personnel without apartments.
Although the material situation of the army has drastically worsened, there were suspicions that there existed some secret fund. Additionally, after the Dayton Accord, the state redirected part of its military investment to the police force, which has taken over some functions of the army. Milosevic did not even try to hide this shift. Even the new authorities in Serbia show much more interest in the police than in the army, although our people are fascinated both with the army and police. Serbia will not independently decide how much will be spent on the army; pacifists can be satisfied with the reduction of military expenses.
However, the current Minister of Defense, otherwise an expert in disarmament and army leaders now support joining NATO's Partnership for Peace program. The army will be reduced numerically, but it must improve its technology in order to join. The Minister of Defense believes that those army reforms will cost us around 7 million dollars, an expense which the army will cover through selling the property it has. Of course, I highly doubt this.
There is public opposition to joining Partnership for Peace. Only Bosnia and Herzegovina and Serbia and Montenegro are not members. Our Minister claims that by joining Partnership for Peace, the Czech Republic, Poland and Hungary increased the amount of foreign investment in their countries threefold.
Taking into consideration the events in Iraq, we can see that the army, military expenses, is used for economic purposes. Our current government is of the opinion that Serbia will never again wage war, that attack or defense is no longer our focus, but that the fight against terrorism is.
A FEMINIST-ANTIMILITARIST APPROACH TO SECURITY
STASA ZAJOVIC, WOMEN IN BLACK, BELGRADE
THE TRADITIONAL APPROACH TO SECURITY
The concept of "national" or state security as exists in western states with developed democracies as well as in states with incomplete democratic institutions like Serbia is based on the power of the state. That is, security is based on military and police force, the judicial system that protects the state, its order, and the elite in power.
WHAT ARE THE CHARACTERISTICS OF A TRADITIONAL SYSTEM OF SECURITY?
- The question of security is entrusted to the state, which supposedly defends and protects members of the community from exterior and interior dangers. Feminist theoretician and researcher Eric Blanchard says that the “discourses of national security are part of the elite world of male high politics. Citizens very rarely take part in the creation of the concept and practice of national and state security, except as subjects or 'informers'."
- The issue of security is mostly reduced to the military and police dimension. Eric Blanchard states that discussions of security, especially on the international level, are "spinning the issues of war and peace, with a particular focus on military strategy." Another aspect of traditional security is the militarized economy, which produces deeper insecurity and greater inequality that hurt the poor, especially women and children. All of this leads to local, regional and global militarization.
- The invisibility of women and issues concerning women.
- The visibility of women only if they are serving the state and nation, giving birth to advance national security. If women are mentions, they are referred to exclusively as objects to be used by the nation, state and church. According to nationalist-militarist rhetoric and propaganda, all women are mothers, but it is important that mother and children have certain ethnic worth. In other words, giving birth is important only if it increases the majority/Serbian nation. Serbian nationalist demographers, and most demographers hold nationalist views, constantly emphasize the danger to the state from outside and that giving birth does not only prevent the extinction of the Serbian people but also is the way ‘to defend our territories.’ Therefore, childbearing should be a function of national security and defense. Reproduction is only valuable if it produces children of a particular sex (male) and ethnicity (Serbian) within marriage. This example points to the direct connection between sexism, nationalism, and militarism.
WHAT VARIETY OF SECURITY IS THERE IN SERBIA?
There is not basic security in Serbia, which means it is impossible to protect one’s basic existence and property. During the war period and the Milosevic regime, crimes committed in the name of ‘higher patriotic goals and national security’ were legalized. The legacy of that regime is a society in which organized crime and high risk behavior predominate. We live in a pathological community that became accustomed to the abnormal. Militarization, on the institutional, ideological and cultural levels, leads to the circumstance that, even though Serbian society does not have elementary security, the most trusted people are those who are supposedly in charge of security and defense.
In the last ten years, public opinion polls have shown that the army and church are the most trusted institutions in Serbia. Research conducted by the Center for Civic-Military Relations in June/July 2003 shows that the army is trusted by 72 percent of the Serbian population and 55 percent of the Montenegrin population. Even though the army was defeated in the last four wars, it still is the most trusted. Most of those interviewed mentioned that their reason for giving a vote of confidence to the army was “the army guarantees peace and security" and that it is "connected with the people." In response to the question of whether or not the Yugoslav Army (VJ in Serbian) has committed war crimes, 26 percent of respondents denied that "our army has committed crimes in the region of the former Yugoslavia." Fifty-nine percent of respondents believe that the VJ respects human rights.
About ensuring other aspects of security (social, political, and cultural) of citizens, regardless of their ethnic, sexual, or religious allegiance, nothing can be said. According to UNICEF’s April 2003 report, approximately 200,000 children live in conditions of extreme poverty, while 600,000 children live below the poverty line. Unemployment in Serbia has exceeded 1,000,000 (the total number of employed persons is 1,820,000) and disproportionately affects women.
WHAT IS THE CONCEPT OF HUMAN SECURITY?
The concept of human security is based upon civic values, on the assumption that human beings are the primary subjects of security. Human security asserts that security cannot be achieved through the military, but only through policies that appeal for dialogue and the satisfaction of basic needs. The concept of human security is dealt with on the institutional level and by global civil society, that is, by alternative feminist-pacifist networks.
What is meant by human security?
- Protection of the civilian population in armed conflicts and a constant effort to ensure justice, respect for the law, democracy and disarmament;
- Establishment of funds for human security in the post-conflict period;
- Promotion of fair trade and a global market that will benefit the world’s poorest and enable the development of a just and effective global system;
- Universal access to healthcare, the right to elementary education, and a basic standard of living for all. Nobel Peace Prize winner (1981) James Tobin has proposed the introduction of an international tax on all financial transactions that could solve all of the aforementioned problems globally;
- Respect for the freedom of all individuals to have plural identities and choices;
- Protection of people from armed conflicts, from the illegal arms trade, and other violence.
UN SECURITY COUNCIL RESOLUTION 1325
The passage of Resolution 1325 on October 31st, 2000 was a historical event. For the first time, the UN Security Council appealed for the inclusion of civil society, specifically women, in peace processes and in the application of peace agreements.
This resolution is practical support for women's groups that are engaged in peace building.
Resolution 1325 concentrates on four fields:
1. The participation of women in peace processes;
2. The inclusion of a gender perspective in peace processes and training to promote a gender perspective in peace missions;
3. The protection of women in crisis and war areas from violence, especially from rape;
4. The inclusion of a gender perspective in UN reports and mechanisms for the implementation of peace agreements.
WHAT IS THE CONCEPT OF SECURITY FROM A FEMINIST-ANTIMILITARIST STANDPOINT?
The feminist theory of security (FTS) is based upon the following principles:
- Recognition of women's experiences
- Exploration of women's invisibility in international security politics;
- Reexamination of the concept of ‘protection’ given to women by the state in times of both war and peace and the issues of women's everyday insecurity in the local and global patriarchal system. The question that must be asked is ‘does peacetime include peace for women?’ Eric Blanchard begins from the standpoint that "the state is part of the structures that allow women to become the objects of men's social control, not only through direct violence (murder, rape, domestic violence, and incest) but also through ideological constructions such as 'women's jobs' and the cult of maternity, that justify structural violence, such as inadequate health services and widespread sexual harassment. Therefore, the state is women's false 'protector;'"
- FTS investigates and questions the relationship between women, security, peace and war. Eric Blanchard identifies three possible feminist approaches to peace:
1. The position that accepts stereotypes about men's violence and women's peaceful nature and peace potential;
2. The position that rejects gender differences and represents women's right to an equal presence in the issues of war and peace;
3. The standpoint that attacks militarism and claims that war is a consequence of patriarchy, i.e. that war is rooted in military patriarchal structures and gender roles;
- According to the antimilitarist standpoint, the paradigm of 'defense' is replaced by the paradigm of 'security.' The antimilitarist collective Contagious Utopia (Utopia contagiosa) in Madrid is known for its significant creative contribution to antimilitarist theory and practice. Members of the collective believe that the use of the term ‘security’ is vague about the role of militarism, allowing this term to take on a very broad and open meaning. This vagueness allows the army to become the embodiment of ‘good’ in the struggle against the drug trafficking, natural disasters, terrorism, undocumented migration, humanitarian catastrophes, and other national crises. Contagious Utopia connects this with the growth of global militarization. "Militarism spreads in various ways, and constantly reorganizes itself in order to strengthen the mechanisms of social control through the use of tactics that aren't considered to be military (including repressive apparatuses, reform and insecurity in the job market, personal security, immigration laws, and militarist elements in the educational system).
FEMINIST-ANTIMILITARIST SECURITY INCLUDES THE FOLLOWING:
- The security of people, not of states. Human needs, not states' needs, are primary;
- Demilitarization on all levels: more arms doesn't mean higher security. As military expenses increase, security decreases;
- A fair distribution of resources: security can be achieved only if national, funds are used not for rifles and bombs but for the health and wellbeing of people worldwide. Therefore, "security is developing a concept that means security from hunger and repression, as well as protection from unexpected and painful turns in peoples' lives" (Likhaan, Philippines);
- Women's common work against militarism outside of and above state and national borders in order to create a world without military violence: soldiers that commit violence on the front, in military bases, or wherever they are located, become more violent against their female relatives once they return home. That is why it is necessary to consider the continuum of violence on the private and public planes, on the local and international levels (Pacific Women’s Antimilitarist Network).
HEALTH IS A BASIC HUMAN RIGHT - THE STATE’S RESPONSIBILITY FOR WOMEN'S HEALTH
ELISABETH EISING, WOMEN'S GLOBAL NETWORK FOR REPRODUCTIVE RIGHTS, AMSTERDAM:
The Women's Global Network for Reproductive Rights (WGNRR) has existed since 1978. It is an autonomous network of groups and individuals from all continents who act in benefit of women's reproductive and sexual rights.
On May 28th, 2003, WGNRR began a campaign for primary healthcare in cooperation with women and men worldwide, including in this region. The campaign aims to motivate and connect women's groups, groups who deal with health issues, youth groups, as well as other social movements that share this concern due to the constant worsening of health services for women worldwide.
At the conference of the World Health Organization held in Alma Ata, a declaration was adopted which obliged the signatory countries to reach the goals set by the program ‘Health for All’ for primary healthcare by 2000. The declaration is addressed to all public health systems and it demands satisfying the needs of the poorest. All health care should be considered as a basic human right.
However, 25 years after Alma Ata, health services in and the conditions that affect women's health and their ability to decide about maternity and sexuality have worsened in most countries. Many governments didn't even adopt the basic indicators established by the program ‘Health for All.’
The growth of fundamentalism, which opposes women's rights, and the neo-Malthusian approach to demography that prevails in many development programs are obstacles to the realization of women's reproductive and sexual rights. One of the most significant causes of the declining health services and health conditions are reforms of the health sector. These reforms are directed exclusively by market criteria that regard healthcare as a product, not a basic human right.
The reality that women worldwide are facing is more than somber:
- Women make up more than 70 percent of the 1.3 billion people who earn less than one dollar a day;
- Women's mortality during childbirth is increasing. Women's malnourishment is one of the biggest causes of mortality for women and newborns.
- The number of cases of diseases such as tuberculosis, malaria and AIDS is increasing. This doubly affects women due to their role as informal nurses. Not only do women become sick, they are usually responsible for caring for others who become ill.
- Around 80,000 women worldwide die every year due to abortions performed in inadequate conditions, while hundreds of thousands of women suffer temporary or long-term health consequences from such abortions.
Because of all this, especially because of the fact that the privatization of health services reduces or eliminates states’ responsibility for citizens’ health, during its three years of intensive work the Campaign will exert pressure on governments to assume responsibility, ensure that health is a basic human right, include women in decision-making positions on all levels, and introduce gender analyses into health planning and services.
MARIJANA SENJAK, MEDICA, ZENICA, BOSNIA AND HERZEGOVINA:
The Medica Center was founded in 1993 with the goal of providing medical and psychological assistance to women who have survived rape in war. Our founder, Monica Hauser, a feminist gynecologist from Germany, openly used the word 'rape' while we were still using the phrase ‘violence in war.’ During the past ten years, the center has given holistic help to women, caring not only for their gynecological and general medical health and psychological state of mind, but also addressing women's needs for education and employment. For example, approximate 200 women from Srebrenica were given job retraining in addition to basic health and psychological recovery care.
We have tried to expand our holistic approach to health to include making changes to state institutions. We wanted to move from dealing with the consequences of violence, ‘putting out fires,’ towards preventing the causes of violence. Our educational programs taught police officers, judges, social workers, journalists, and educational workers. Other programs dealt with connecting women from divided communities, such as Mostar, Bihac, and Prijedor. We have also exerted pressure on the state to take care of women who have survived rape in war and to help them find employment so they will be able to attain independence and regain control over their lives. We were also asking the state to earmark funds for their children's education.
Finally, I would like to say something about the experience of health assistance to women victims of sex trafficking. We heard astounding information from the UNICEF representative at a recent regional conference in Budapest. Of the 17,000 European sex-trafficking survivors interviewed, only 63 were given medical or other care! The representatives of the ministries of health from the states of this region spoke about other priority groups that needed health assistance. This was the reason that our women's networks and coalitions decided to request healthcare and greater accessibility to health services as well as free examinations for women who have survived not only war violence but also trafficking and other forms of violence.
VIKTORIJA CUCIC, INSTITUTE FOR SOCIAL MEDICINE, BELGRADE:
No health department in this country is sensitized to any aspect of women's health. The concept of women's health must include a woman's right to self-determination – a woman's right to define what kind of health she wants, what health means to her and how she thinks her health should be. However, health services tend to ‘tame’ women, they demand that women fit into the concept of health as defined by the mainstream medical philosophy. Health professionals speak about biological vulnerability and inherent weakness, while social vulnerability and instability, from which stems a whole host of illnesses, is being ignored. Biological vulnerability exists, but to a far lesser degree than social vulnerability, because the latter is related to a women's ability to be given quality information about her health and to make her own decisions about her health. Additionally, there is a tendency to reduce women's health to the gynecological dimension, which is significant but not the entirety of women’s health. The most important thing is to apply a holistic approach, to recognize a woman in her totality, with all her problems. Since I have been working on the prevention of AIDS since the first case appeared here, I want to introduce to you some findings. UNICEF’s study in 2001 showed that the level of knowledge about AIDS among women is extremely low. Only 7 percent of women in Belgrade believe they know enough about this disease.
In the last ten years, women have borne the greatest burden of war, misery, and embargo. In countries in transition, the life span of women is shorter than that of men. This is also the case in our country.
VALERIJA SABO-TOMIN, EVA, NOVI SAD:
According to investment in military objects, Serbia and Montenegro leads the region, while according to investments in health, it takes almost last place.
A feeling of insecurity and fear significantly affects women's health. One of the agencies engaged in the investigation of fear discovered that one of the leading fears among women is the fear of illness; they are afraid that they will not be able to receive treatment. Health workers have the same fears. There are fears about the impossibility of supporting one's family and educating one's children. Health workers are also afraid of patient's aggressiveness due to the impossibility of providing the expected level of healthcare.
STANISLAVA OTASEVIC, AUTONOMOUS WOMEN'S CENTER, BELGRADE:
The category of women's health is socially unknown, unrecognized by institutions and society as a whole. It is important to raise women’s awareness so they can recognize their rights and not accept what women worldwide do accept—so-called ‘ill health.’ Ill health is the idea that ‘while I am able to accomplish what is expected of me every day, I am healthy, and when I fall into bed, only then am I ill.’ To change attitudes towards health, it is necessary to develop a proactive relationship and holistic approach to health.
MARJAN MURATOVIC YUGOSLAV ASSOCIATION FOR THE CULTURE AND EDUCATION OF ROMA, LESKOVAC:
I am working on the project "Knowledge and Health" whose goal is the advancement of health, health education, and the education of the Roma population.
It is hard to "classify" Roma women as young girls, girls, women, or mothers. Because of early marriage (from age 12 to 14), a Roma woman suddenly enters several classifications. A girl becomes a wife. A wife becomes a mother, a mother who has no knowledge or experience to teach her child, a mother who delivers one more person dependent on public welfare. That is how it goes from generation to generation.
Additionally, because of early marriage, because of a lack of basic information about reproductive health, the number of interrupted pregnancies is large. On the average, a Roma woman has between 20 and 40 abortions. Most of these abortions are not performed in healthcare facilities. Women of reproductive age, who do not want to have more children, and especially women during menopause, do not go to medical checkups. According to our research, Roma women grow old faster; menopause begins between age 32 and 40. Among the Roma population, women's lifespan is shorter than that of men. One of the serious problems that Roma women face is the fear they have of health institutions due to the institutions' tremendous prejudices and the barriers against them.
SLAVICA SIMIC, WOMEN'S CENTER, UZICE:
As a part of the Women's Center, Jefimija, a counseling service for women with breast cancer, has existed for three years. We succeeded in creating a network in Serbia, in training teams in thirteen women's organizations who have opened similar counseling services.
Beneficiaries of our services, that is, women suffering from breast cancer, are supported in becoming activists; we put them in a position where they ‘must’ struggle for themselves. Therefore, not only do we offer services, but the beneficiaries also create support groups on their own that change their lives.
As far as institutions are concerned, we cannot wait for things in this country to change. We are ‘inserting’ ourselves in the institutions; we have established an ‘illegal’ relationship with health institutions. We have a personal, private network in the framework of institutions. Our activists are doctors in surgery and oncology departments, and we have many nurses in our network. Wherever we can, we go into hospitals and provide educational programs.
HEALTHCARE REFORM AND THE PRIVATIZATION OF HEALTH SERVICES
VUK STAMBOLOVIC, PHYSICIAN, BELGRADE:
The Declaration of the World Health Organization (WHO) from Alma Ata (1978) represents a shining moment for that organization, but unfortunately, the WHO quickly changed its mind. At the beginning of the eighties, it said that the ideas of Alma Ata were too ambitious and the WHO began to move in a different direction.
Namely, during the nineties, the World Bank has taken over the leading role on the global health scene. The World Bank follows a neo-liberal political orientation.
WHAT DO REFORMS OF THE HEALTH SECTOR CONSIST OF?
- The introduction of selective and profit-making programs instead of a universal approach to healthcare. A universal approach would mean health for all and as a basic right for everyone, rather than institutional concentration on particular illnesses and problems. Massive, profitable testing and development of new medicines creates profits equal to that of the arms industry. Not only one medication, but also entire series of medications are being promoted, while there is no shift in curability in relation to the time when illness occurred.
- A centralized, vertical program that does not include people in the field or cooperation among different sectors. Instead of generic medications that include traditional medicine, very expensive and inaccessible medications are being produced.
WHAT IS THE ROLE OF THE STATE IN THESE REFORMS?
- The reduction of the state's responsibility to provide healthcare and the concept of the cheap state. What does this mean? Public expenditure for healthcare has been reduced because health is no longer perceived as public welfare but as a commodity.
- The introduction of a minimal entitlement health services and charging for health services. The state has completely changed its role. It has almost no responsibility for citizens' social rights or any responsibility for health as general welfare. The state has two key roles according to World Bank investments designed to reform health services. The state enacts health policy that enables the widening of the market into the health sector. By introducing the minimal healthcare entitlement, the broadest segment of the population—who do not have the purchasing power to buy certain health services—is being excluded. Enormous funds are freed in this way. It has been calculated that the states of Latin America ‘save’ 35 billion dollars that go to the payment of debts. That is the most drastic flow of funds from undeveloped countries to the developed.
- The criterion of technical efficiency is being promoted over the criterion of social justice. Public health expenditures include only those treatments that are profitable and not those that reduce illness.
WHAT IS THE ROLE OF THE NONPROFIT SECTOR?
The World Bank appeals for the participation of the non-profit sector and in particular women because it is more efficient, and less expensive than the state sector. However, in such a market of unregulated health services, a huge number of service providers participate, irrespective of their qualifications and knowledge. Such World Bank policies only appear contradictory. The institution is in fact realizing its fundamental goal - the transfer of funds from the poor to the rich.
HOW DO REFORMS OF HEALTH SERVICES REFLECT THE POSITION OF WOMEN?
- Through the re-traditionalization of women's roles: because of a reduced right to healthcare, women must take on the care of their family members, especially children, the sick, and the elderly. Because of this, her own health needs become even more disregarded.
- Through the dismissal of women from jobs in the health sector, which traditionally employs a large number of women. This increases women's poverty. They become more dependent on men who earn an income. This affects women's physical and mental health.
WHAT ARE THE ALTERNATIVES?
The state must assume responsibility for the health of all citizens and not only women. It is necessary to create of coalitions of solidarity to exert of pressure - every one of us can take on a part of this responsibility. The kind of reform of health services that will be carried out depends on each one of us.
SNEZANA SIMIC, DEPUTY MINISTER OF HEALTH FOR SERBIA, BELGRADE:
The health service system is not a priority for this government. As someone who is part of the government, I am able to declare that it has no kind of reform orientation. All attempts aimed at accomplishing something important have no support.
However, that does not mean that we do not do anything, especially on the topic of privatization. There are two extreme directions in privatization:
1. The group of lobbyists who think that the whole system of health service should be privatized, especially primary healthcare;
2. A group composed of people from the ex-regime (the Serbian Socialist Party and the Serbian Radical Party) who think that everything in the health service system should be free.
I must say that not one health service is free. Many things are now being paid for, but there is also informal payment, which is a euphemism for stealing and corruption. When there is no money for some services to be provided, it is openly said to the patient that they should pay, or through blackmailing them.
I have been in the government for two years not as a party member, but because the Minister of Health asked me to since I work in the field of public health. My professional role is to organize the system of healthcare, to give advice, and to participate in that reorganization. I will now take the time to state what has been done so far:
- New equipment and improvement of working conditions: a lot has been invested. Now, no one can say that there is no equipment or basic working conditions in the larger towns.
- Better coordination of international assistance on the state level: two of the most important partners are the World Bank and the European Agency for Reconstruction. They helped with the reconstruction of hospitals. The World Bank financed the reconstruction of four hospitals while the European Agency for Reconstruction has assisted in the renovation of 20 clinical hospital centers.
- The protection of patients' rights: advocates for patients' rights have been introduced into health centers.
We have a ministry adviser who is responsible for protecting these rights, and advises patients about how they can press charges. A health inspection is sent that can start the procedure if a drastic violation of rights is established.
Private practice is a black hole; during the former regime, private practice was the arena for making a profit. Everyone could start a private medical practice without the obligation to register what he does or how it works. In doing a checkup, we found 20-30 consultants from the state sector working in private medical offices. In World Bank jargon, that is referred to as passive, uncontrolled and spontaneous privatization. We were aware of this, but at this moment we have no capacity to confront this problem or to change something at the level of the Ministry of Health. Among the clinical staff - who have a strong lobby and all are working in private practices - there is not much will to clear up this situation. I can see generally that there is not much will for any sort of reform. Regardless of what you want to change, it turns out that it is the status quo that is satisfactory while everyone is only declaratively in favor of change.
Private practitioners would like all to be privatized in the health care system, for three reasons:
l. We have a large number of health workers in the healthcare system; It is said that there is a 20-30% surplus. The World Bank proscribes a 5-10% surplus. According to recommendations that we have received, dentistry on the primary healthcare level will be privatized. Preventive and urgent dentistry services will be kept public because they are in the state's interest and should be provided. Persons over 18 years old would have to pay for the services, which is unfair from a socioeconomic standpoint.
2. The redefining of the network of health institutions that the state finances. this means that some health institutions will be outside the network. Rehabilitation centers and parts of large health systems will be privatized. They will be sold in order to obtain the funding to renovate what remains in the public sector.
3. The redefining of the package of services. We must determine what should be guarantee by insurance and the services that the state cannot include in this package and which everyone will have to pay for themselves.
WHAT CAN WE DO?
We will try to ‘force’ every health institution to provide the services that people are entitled to and we will continue to promote the protection of patients' rights on the level of health institutions.
With insurance, it has been agreed that people who use private health sector services will pay a part of the sum, often between 25-30%. That will be doubly useful: private practitioners would enter the health care system and their position as a provider of services would be equalized.
Prepared by: Stasa Zajovic
