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Abstract

A ‘social pact’ for health is a fundamental part of processes of political change, extension of democracy and exit from armed conflicts. Post-war national experiences, and the early role of the WHO have introduced a view of health as a universal social right, to be protected by universal public services. The political context shaping such debates and policies was characterised by advances of democracy, development of welfare systems, a search for greater equality, a key role of public intervention. Key cases that will be addressed in this paper include the UK of the Beveridge Report during and after world war II; Italy from the 1948 Constitution to the late implementation in 1978 of a radical public health service; post-dictatorship Brazil since the 1980s with the development of public health systems; and more recent cases of post-conflict societies. Lessons on the role of health in political and social change will be drawn, highlighting the potential for action and democratic advances.

1. Introduction

The emergence of health as a universal social right and the establishment of public health services have been important developments in the past century. After world war II, the UK opened the way to the creation of the welfare state with a key role played by the National Health Service. In Italy, the Anti-fascist Resistance produced the first ideas about a public health system, that were introduced in the 1948 Constitution and turned into reality with the 1978 health reform. Similar developments have been experienced by post-dictatorship Brazil and by countries emerging from armed conflict.

It appears that a sort of ‘social pact’ for health is a fundamental part of processes of political change, extension of democracy and exit from armed conflicts at the national level.

At the same time, at the international level, the creation of the WHO in 1946 and its definition of health as «a state of complete physical, mental and social well-being» of every individual and of society as a whole was a key development that emerged even before the United Nations Universal Declaration of Human Rights of 1948. These actions by the WHO opened the way to a global perspective on health, well beyond national dynamics.

Such a wide-ranging view of health as a key condition for human life plays a crucial part in the emancipation of individuals and societies; this requires a radical rethinking of the relationships between human beings, nature and society, questioning social, economic and political structures. The view of health as a universal right and the development of public health and welfare systems have invested the daily life of all, changed the social relations of production and reproduction and have become core political issues for the advancement of democracy, social struggles and progressive politics.

2. The postwar context

Already during the Second World War and immediately afterwards, in several countries a new vision of health emerged, with the prospect of reshaping the organization of society, power relations between citizens, classes and institutions, the key structures of postwar democracies. At the national level, the assertion of health as a social right was intertwined with broad political changes, the goal of greater equality, the guarantee of fundamental freedoms, the expansion of redistributive policies and the welfare state. At the international level, the ending of the Second World War opened the way to a global perspective on health as a cornerstone of a peaceful international order, as envisioned in the early documents of the WHO.

The first declaration of the WHO (1946) stated that «The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest cooperation of individuals and States». It added that «the achievement of any State in the promotion and protection of health is of value to all»[1].

The following topics emerge as important issues to be investigated.

Health after conflicts. Armed conflicts are a direct threat to human life and a new appreciation of the value of human health usually emerges after the end of wars. Topics to be addressed include the ways in which social activism, political projects and actual policies can express such new social orientation and achieve concrete change.

The individual and social dimension of health. The combination of individual and social dimensions of health opens up the space for recognising the relational nature of human beings and the need for  collective action and public policies in this field.

Health and welfare. Health reforms have always been part of a broader set of political changes including social protection, education, housing etc. with a major role of public service provision outside the market. This has changed, to some extent, the nature of postwar capitalism in Europe and remains a key terrain of conflict among alternative models of society.

Health, work and the environment. Working conditions are a major factor shaping individual health; environmental quality is a key driver of social health. Health policies cannot be developed in isolation from these two major contexts and both the labour and the environmental movements have paid, in some cases, close attention to health issues, developing mobilisations, alternative practices and policy alternatives for preventive and territorial health.

Health, equality, democracy. Universal public health systems are a crucial factor for reducing inequalities and introducing participatory democratic practices. The links between these dimensions are important aspects of a political agenda in this field.

Health and hegemonic political projects. In the cases that will be discussed, success in health reforms was made possible by a combination of widespread social awareness, active mobilisation of unions, social movements and experts, far-sighted political projects of Left parties building broad political alliances, strong capabilities for implementing public policies by public institutions.

3. The case studies

3.1 The UK, from the Beveridge Report to the creation of the NHS

The publication of the Beveridge Report (Social Insurance and Allied Services, 1942) marks the official appearance of the welfare state in the international policy agenda. After this Report, the concept of social security was progressively adopted by most countries as a cornerstone of their social policies.

The reorganization plan of the British social security system was presented to Parliament in 1942 by a commission chaired by William Beveridge. The Labor governments of 1945-51 adopted its objectives and introduced important social legislation. The war was seen by Beveridge himself as an opportunity for the creation of a new and more just order. ‘Freedom from want’ was the key goal of the Beveridge programme, during and after the war. In the section Planning for peace in war, Beveridge stated that «Each individual citizen is more likely to concentrate upon his war effort if he feels that his Government will be ready in time with plans for that better world; […] if these plans are to be ready in time, they must be made now»[2].

The new social order would thus emerge from the sacrifices shared during the war, from the common experiences, from the sense of solidarity created in the war context. As pointed out in the comment by the historian Pierre Rosanvallon on Beveridge, the war showed that «all British citizens, rich or poor, are equal in the face of German bombs»[3], and this had profound consequences in the planning of programmes for reducing inequalities, redistributing income, protecting against social risks. Similarly to what happened in the First World War, there was a widespread perception of a “social debt” to be honored with programmes for “a better world”.

The commitment at the base of the Beveridge Report was the fight against the main deprivations of society; this effort distinguished democratic nations from their fascist enemies. The war could be won if it appeared as the opportunity to replace the ‘old’ world of privilege, injustice, deprivation with a new order ensuring freedom from need[4].

The Beveridge Report envisaged a «comprehensive policy of social progress» addressing not only want, but also «disease, ignorance, squalor, idleness»[5], as well as war, the last of the gigantic evils that afflict the world and have to be overcome in the pursuit of peace and international justice.

The new social security system was to provide protection against social risks for all citizens, not just to workers covered by occupational insurance schemes, and offer benefits equal for all, based on a “national minimum” essential for a dignified existence. The guarantee of an adequate income, sufficient to face the responsibilities every citizen has to face in the course of his life was a fundamental part of the Plan, intended for the entire population and not only for the weaker groups, on the basis of a new social contract between citizens and society.

In order to pursue the objective of «freedom from want»[6], the Beveridge Plan proposed a complete and universal health service: «the whole population will be covered by a comprehensive scheme of medical treatment and health services, […]  in place of the more limited existing medical benefit, a substantial improvement in the health of the community»[7].

Of great importance were the sections devoted to Health and Rehabilitation Services: «A comprehensive national health service will ensure that for every citizen there is available whatever medical treatment he requires, in whatever form he requires it, domiciliary or institutional, general, specialist or consultant, and will also ensure the provision of dental, ophthalmic and surgical appliances, nursing and midwifery and rehabilitation after accidents»[8]. The plan was based on a close collaboration between the state and the individual and on the commitment of the entire community to solve the most urgent needs.

These policies were implemented by the Labor governments led by Clement Attlee including reforms of public health, education, social housing, the nationalization of some key industries and infrastructures, based on a universalist and democratic welfare state, consistent with a socialist political agenda.

The National Health Service (NHS) was established by the National Health Service Act of 1946 and came into effect on 5 July of 1948. Its fundamental characteristics were its financing through taxation and its universal reach, while before the NHS only 20 million British citizens had a system of healthcare protection. A major role was played by the Minister of health Aneurin Bevan, a leader of the left in the Labour Party, who argued that «A free health service is pure Socialism, and as such it is opposed to the hedonism of capitalist society»[9].

The NHS was designed with an overall responsibility of the Ministry of health, with three main divisions – Hospital and specialist services; General practitioners services; Local authority health and welfare services – with a decentralized structure over the country as a whole. At its start, the NHS had 5,000 doctors, 125,000 nurses, 480,000 hospital beds.

A massive communication effort was organised to explain how the NHS would work and 97% of citizens chose to use the Family doctor services. Most doctors opted to work for the NHS, while maintaining the possibility of a private practice. Free coverage was granted also to temporary residents in the UK[10].

The NHS has since become a model for universal public health services all over the world, but it is important to point out its links to the wide-ranging social reforms of the post-war UK under Labour governments that included new social services schemes, large-scale provision of public housing, an income security system, improved pensions, implementing the agenda of the Beveridge Report discussed above, with a system of protection “from the cradle to the grave”.

As pointed out in the introduction, the success of British health reform relied on the roots in wartime debates on social reform, on the widespread consensus – especially from the working and middle classes – on the government responsibility towards its citizens on issues of social rights, on a comprehensive view of the emerging welfare state, and on the success of the Labour Party political agenda of radical reforms.

3.2 Italy from the Constitution to the creation of the National Health Service

In Italy, the development of a universal public health service, financed through the general tax system and guaranteed to all citizens, was the result of a long process that accompanied the fundamental transformations of the country. Its start was in the aftermath of World War II, in the Anti-fascist Resistance, and in the drafting of Article 32 of the Italian Constitution, which introduced a new, advanced definition of the right to health.

In the summer of 1945 the National Liberation Committee – who had led Italy’s Resistance struggle – established a Health Council in the Veneto Region which drafted the first proposal for reform of the Italian health system. The main author was Augusto Giovanardi, a professor of Hygiene at the University of Padua. The project criticized the existing system for the lack of a single health authority, for the unacceptable territorial differences in levels of services, especially between city and countryside. The proposal envisaged a radical reform of the health and welfare systems, based on a decentralized structure. In several aspects it was an anticipation of what emerged, thirty years later, with the Servizio Sanitario Nazionale, Italy’s NHS[11].

In the summer of 1946 work began on the preparation of Italy’s new Constitution, which was introduced in 1948. Article 32 states that «The Republic safeguards health as a fundamental right of the individual and as a collective interest, and guarantees free medical care to the indigent. No one may be obliged to undergo any health treatment except under the provisions of the law. The law may not under any circumstances violate the limits imposed by respect for the human person». In the Constitution, health appears as the only “fundamental” social right[12], as a prerequisite for the full realization of the human person[13].

The right to health, in its individual and social dimensions, is defined as the psycho-physical integrity of the human person, understood not as the mere absence of disease, but as a «state of complete physical, mental and social well-being», adopting the definition provided by the WHO in 1946.

As a fundamental right of individuals, the right to health is addressed to everyone, and the Republic has to provide all the ways of preventing and treating diseases. Article 32 guarantees “free care to the indigent”, that is, to those without economic means and in need of special protection. There is a public commitment to the development of universal healthcare and the affirmation of a principle of substantial equality with the requirement that

free care be provided to the poor. The right to health includes preventive, curative, rehabilitation healthcare and hospital activities. A further aspect that emerged, especially in the 1960s and 1970s, is the link between the constitutional protection of health and environmental quality, i.e. the right to a healthy environment.

In short, the view of health of Article 32 of Italy’s Constitution combines individual rights and the interest of the community. The implementation of the right to health requires political choices that involve the entire population, changes the nature of democracy and the social and economic structures of the country. This perspective opened up a new relationship with environmental and occupational health, where prevention and participation became crucial factors.

This approach leads to a reconfiguration of power relations between citizens and institutions; there is a shift from the individual relationship between patient and healthcare provider, to a view of collective health that has to be rooted in communities and workplaces. In this trajectory, new actors were mobilised, questioning the conditions of production at work, and the forms of social reproduction in cities and families, as a part of a broader process of democratization of society.

Italy had to wait thirty years before the constitutional principle could be implemented in practice, with the creation of the National Health Service (Servizio Sanitario Nazionale, SSN) that introduced a radical reform in 1978 (Law no. 833 of 1978). A key role was played by the parties of the left (the Communist and the Socialist Parties), by some social Catholic groups, by the Left trade union (CGIL) and by social movements, including the students movement, feminism, the radical groups active in the fields of psychiatry and medicine, that were particularly strong in the 1970s.

Over these years important experiences and regional experiments were carried out, new practices of struggle developed in cities and workplaces, a radical view of the social function of medicine emerged. The concept of territorial social services – provided to all by public institutions – also emerged, as an answer to the demands for collective services, contrasting the Italian tradition of occupationally-based, insurance-oriented welfare. All these experiences were crucial in shaping the health care reform of 1978.

The creation of the SSN in 1978 reflected the demands for political change and democratization emerging from the social conflicts of the late 1960s and 1970s. A strong  pressure from below challenged the medical and health policy establishment, introduced participatory practices in healthcare and was part of a wide-ranging intellectual ferment. We can therefore speak of a “political” origin of the universalist, public and decentralized structure of the SSN, which was characterised by a vision of health as a social and political issue, by an integrated approach to social and health needs, by the centrality of the preventive and epidemiological approach, by a decentralised territorial organization, by attention to the links to working conditions and environmental protection. In this trajectory important figures had a major influence, including in particular Giovanni Berlinguer[14], Giulio Macaccaro[15], Laura Conti[16], Ivar Oddone[17], Franco Basaglia[18]. They were rethinking and renewing the medical-health system and the relationship between medicine, society and politics. They provided an important connection between medical institutions, universities, political forces and trade unions and were crucial for the birth of the SSN[19].

They had different roles and competences, but shared a vision of health as a social and political issue, set in the context of the social consequences of advanced capitalism. Their integrated vision of health, linked to the community and the territory, was important in shaping the characteristics of Italy’s SSN.

In spite of the long delay, the creation of Italy’s SSN was, most of all, a political victory for progressive forces, resulting from a far-sighted “politics of alliances” among all the actors mentioned above[20].

The approval of the law that established the SSN, in December 1978, obtained a very large parliamentary majority and took place with Tina Anselmi as ministry of health; she was a progressive Catholic, member of the Christian Democratic party, had been active in the Resistance and the first woman to hold the position of minister of health.

The key elements of Italy’s reform include the following ones: a universal health protection for all, with services provided by the State and financed through general taxation; a territorial decentralization of health services, guaranteeing uniform standards throughout the country; a focus on preventive medicine and the epidemiological approach; the democratic participation of political and social forces, health professionals and citizens in the definition of policies and the management of services.

It is important to point out that Italy’s reform was approved after the WHO conference of Alma Ata (September 1978) in which primary healthcare was identified as the main tool to achieve the goal adopted in 1977 by the World Health Assembly: «Health for all by the year 2000». This goal was to be achieved through the development of basic healthcare services, based on the principles of universal access, equality, participation and prevention, as stated in the 1978 Declaration of Alma Ata.

3.3 Brazil, from the return of democracy to the Constitutional right to health

In Latin America, and especially in Brazil, in the 1970s and 1980s the struggles for democracy against military dictatorships were linked to demands for social rights, including the right to health, seen as an integral part of a single project of social emancipation and political liberation.

In Brazil, the movement for the right to health and for a public healthcare system based on social medicine developed from the new relationships between political forces, social mobilisations and health experts; alliances were created between workers, university researchers, medical professionals and civil society organizations.

A key element of Brazil’s experience was the push towards a politicization of health, seen as a key component of the democratization process. Struggles for democracy therefore were closely connected to those for a “democracy of health”. The major result was the drafting of a Constitution in 1988 which paid special attention to the right to health, its protection and promotion, and to a democratic, participatory and decentralized organization of the health system (“Sistema Único de Saúde”, SUS). At the center of post-dictatorship health policies were the themes of prevention, the epidemiological approach, attention to the social and environmental determinants of health, collective responsibility and involvement, the principle of universal coverage, the fight against the strong social inequalities of the country.

Health policy thus became the center of processes aimed at affirming a democratic order based on the principles and practices of social justice and equality, aiming at improving the “quality of life of the population” and at the reduction of inequalities[21].

The most significant political debates on the health conditions of the Brazilian population began in the mid-1970s, in a political and social context marked by the authoritarian rule of a military dictatorship, which started in 1964 and ended in 1985. In this critical period, the Health Movement and other political and social movements were born. Of particular importance was the role of women, already active since the mid-1970s in several cities in Brazil, demanding a new model of integrated (”whole”) public services for collective health and social services. To pursue these goals, a major contribution came from the Grupo Temático Gênero e Saúde of the Abrasco organisation (Brazilian collective health association, born in 1979 as Collective Health – Abrasco) and from the Programa de assistência integral à saúde da mulher (PAISM) created in 1983[22].

While the previous health policy paradigm aimed at the control of the population and to the regulation of individuals, the new view of “collective health” became important in the debates on Brazil’s health policy[23].

The pressure from social movements demanding health reform led the military government to convene the VII National Conference on Health in 1980, which addressed the extension of health measures through basic services, in the perspective of primary health care. The Conference was based on the recommendations of the 1978 Alma Ata Conference, where Primary Healthcare was established as a key international recommendation for health policy. In the 1986 VIII National Health Conference thousands of participants from political and social forces demanded a radical health reform. “Democracy is health” was the central theme of the Conference, emphasising the mobilization for a decentralization of the healthcare system and for the implementation of appropriate social policies. One of the recommendations of the VIII Conference was the creation of a National Commission for Health Reform by the Ministry of Health, which would contribute to the elaboration of the new Federal Constitution of Brazil, focusing on health issues.

After extensive deliberation, the Federal Constitution of Brazil was launched in 1988. The reduction of social and regional inequalities, the promotion of the common good and the construction of a society based on solidarity without any form of discrimination, became objectives of the Brazilian state. These objectives qualify the view of citizenship rights and government duties, including in the area of health[24].

In the Constitution, the sections referring to health (Titolo VIII, Chapter II, Section II, articles 196-200) affirm the view of “health as a right of all and a duty of the State” and establish the

“Sistema Único de Saúde” (Single health system), which was regulated two years later by the General health law (nº 8080/1990 and nº 8142/1990).[25] These laws have provided the legal foundations of the right to health and of the organization of the healthcare system. Health was proclaimed a fundamental human right, which the state had to guarantee, providing the necessary conditions for its full exercise. The results of the struggles for health reform were clearly visible in this achievement.

The state’s duty to ensure health included on the one hand the preparation and execution of economic and social policies aimed at reducing the risk of disease and, on the other hand, the actions needed to guarantee a universal and equal access to health services. Of great importance was the concept of ‘wholeness’, an integrated view of health, seen in connection to its determining and conditioning factors, including food, housing, sanitation, environmental conditions, work, income, education, transport, leisure and access to essential goods and services.

In the “Sistema Único de Saúde” the health promotion strategy moved from a consideration of the essential factors generating diseases, including violence, unemployment, underemployment, lack of basic sanitation, housing inadequacy, difficult access to education, hunger, disorderly urbanization, inadequate air and water quality. The guarantee of appropriate health standards was thus an expression of a new social and economic organization of the country.

The organisation of the “Sistema Único de Saúde” was based on a decentralized network of service centers providing universal access and coverage, envisaging active social participation and an integrated health care. A key role was played by a broad concept of health, the need of public policies to promote it, the relevance of social participation in the construction of the health system and policies. The expression “Single health system” (“Sistema Único de Saúde”) meant that these principles were to be applied throughout the national territory, under the responsibility of the three autonomous spheres of federal, state and municipal government.

The strong social dimension in health policy allowed Brazil to move beyond a purely biomedical approach, addressing the symptoms of disease only.

By encouraging the role of citizens and communities in healthcare and the mechanisms of social participation, the “Single health system” of Brazil can be seen as a key part of the country’s institutional and political change after the end of the dictatorship. The protection of health emerged as an irrevocable social right, linked to other human and citizenship rights.

The creation of an inclusive health system meant for Brazil a wider and deeper democratization of the country.

In this trajectory of political change and health reform an important role was played by international networks, including “Alames” (Latin American Association of Social Medicine) and Cebes (“Centro Brasileiro de Estudos de Saúde ”)[26]. Networking activities extended also to Italy, where – as shown above – major political changes and health reforms had been achieved. An important role was also played by the Italian politician and health expert Giovanni Berlinguer, who in the late seventies and eighties travelled widely in Latin America, participating to scientific and political events and providing technical and political advice to social organizations and governments on how to achieve health reforms, sharing the lessons learned in Italy’s struggles[27]. The Italian health reform experience was influential in the development of health policies in various Latin American countries, affecting both academic training and political movements active on health.

In El Salvador, for example, at the end of the guerrilla war in the late 1980s, the construction of peace agreements between the revolutionary front who fought for democracy and the authoritarian regime that had ruled the country for decades included discussions on health reforms where Giovanni Berlinguer played a role as an expert. In Brazil he participated in several “National Health Conferences” during the 1980s as a public health specialist.

3.4 Health in post conflict contexts

In the contemporary world health has emerged as a key issue in the context of post conflict political change, in ways that are reshaped by the new nature of armed conflicts and by the different policy capabilities of States[28]. A growing literature has addressed this issues considering the following aspects:

– many contemporary conflicts are civil wars or intra-state armed confrontations; here the challenge to the political power of national government is a key issue at stake, questioning government authority on policy making, including actions in the healthcare field.

– international and global health policy institutions, starting with the WHO, have a growing relevance in setting priorities for health action at the national level, especially in the case of pandemics and major diseases typical of poor countries.

– health policy has acquired a greater international dimension, with a growing role on non-governmental actors involved in humanitarian aid and health provision; these developments may contribute important new resources especially during health emergencies and in the reconstrucion of health services, if an adequate coordination of efforts exists; however, such a broader set of actors may bring new constraints to local health policy.

– individual and community health are increasingly connected in post-conflict contexts due to the legacy of wars on physical and mental health, including permanent injuries and collective trauma[29].

3.5 The case of Rojava

The most interesting contemporary case of a health policy agenda emerging from a post conflict situation is that of Rojava, the Autonomous Administration of North and East Syria (AANES), the autonomous region under the control of Kurdish forces and their allies, that has emerged after the tragic civil war in Syria and is still under threat from the Assad regime, the Turkish invasion, and Islamic fundamentalism.

The political project of Rojava is rooted in a democratic confederalist vision, that includes the construction of democratic self-government institutions, the adoption of an advanced legal charter («Charter of Social Contract»)[30], and a strong role of women in defence and policy fields.

The aim of this important democratic experiment is to create a society based on democracy, ecological principles, gender equality and community participation, moving beyond nationalist ideologies and the capitalist model[31].

Rojava lacked a formal state, had to face military threats from different sources, had little economic resources, suffered large war destruction and had to deal with a large number of refugees. All this represented major challenges for addressing health needs. The policy response developed in Rojava has built on the strong political consciousness of communities, on a large-scale mobilization of society, on bottom-up arrangements in the field of health and social support, on international solidarity and aid from important actors.

The most important health policy issues in the case of Rojava are the following.

1. In political terms, we find a view of health as strongly rooted in society, with the promotion of broad processes of politicization of the population on this terrain. A doctor who is a member of one of the health councils of Rojava, argued that problems related to health are connected to the broad prospects of social life, and therefore have to  involve the population, in an integrated vision of health, nature protection and political activism. [32] These are areas that cannot be separated from each other, in an overall rethinking of the conditions of individual life, and of the system in which individuals and community interact. Dilar Dirik, activist of the Kurdish Women’s Movement states that «the politicization of society and the correlation between individual health and the health of society and the environment are of fundamental importance for the health philosophy of Rojava»[33].

The vision for care and health promoted in Rojava is that of self-determination and mutual solidarity, elements that are relevant for the overall political organization of society. In the efforts for a democratic re-construction, actions for providing social care and individual health become crucial elements of a “good life” [34]. With this approach health is not anymore a question of illness, but becomes part of the quality of social life, requiring novel policies and social practices.

2. In terms of governance, the key characteristic is the development of self-government of communities in the field of health, social services, education and the environment. This has empowered communities, favoured participation and flexibility in addressing major local health needs.

3. In terms of specific health problems, major efforts have been directed towards caring for war injured patients and civilian casualties, providing basic health services, developing territorial medicine, increasing the health awareness of military and civilians. “Homes for the wounded” were built, where the injured could recover both physically and psychologically and their reintegration into society was organised.

4. In terms of social actors, a key role has been played by women, who have organised health educational programmes, run local health services, provided care and social reintegration efforts. These actions are part of the broader role of the Kurdish women’s movement in all fields, from military defence to economic activities, from education to health and environmental protection. The women’s role is becoming a key factor in the reconstruction of Rojava, affecting peace-building, democratic participation and changes in gender relations.

5. In terms of actors operating in the health field, the Rojava experience has introduced important new arrangements. A key role has been played by the Kurdish Red Crescent, an independent non-governmental and non-profit organization that was established on 2012, in agreement with the Autonomous Administration of North and East Syria. Its aims are to meet the life-saving health needs of the people affected by the conflict in Norh-Eastern Syria. The Kurdish Red Crescent is the main local actor providing health services as an independent humanitarian organization that works in accordance with humanitarian principles, neutrality and without discriminations.

New forms of cooperation have emerged with international donors, international organizations, NGOs active on the ground and the local policy making and services provision systems. An important example is the collaboration between the Kurdish Red Crescent and the Italian NGO “Un Ponte per”, an international solidarity association active in humanitarian aid, distribution of medicines, primary health care programmes, construction of medical facilities, protection of women and children and in the reconstruction of the health system after armed conflicts. Both organisations operate in Rojava for implementing the right to health, developing a comprehensive model of primary healthcare, with the adoption of a participatory approach, empowering individuals and communities in achieving self-determination and equal access to health[35].

The combination of these developments in Rojava provide a picture of great interest for a revival of health policies in the contest of political and social change in post-conflict countries.

4. New perspectives on health and political change

From the experiences of post world war II in the UK and Italy, to the post-dictatorship case of Brazil in the 80’s, to the contemporary case of Rojava we find a striking continuity of the importance of health systems as a key element in the deep political change experienced in all this countries, as a key component of the affirmation of social rights, of the ability to address major health and social needs, of the democratization processes and empowerment of the subaltern classes and women.

The conceptual approach and the case studies examined above show the relevance of health as a key issue in processes of political change. What lessons can be learned for political action in post-conflict societies in this regard?

1. A ‘social pact’ on health appears to be an important component in periods of expansion of democracy and exit from armed conflicts, when societies have to reassess their values and collective priorities. The nature of health as a social right and as a condition for individual and social wellbeing creates the space for a political vision and action that links the transformation of society to healthy living conditions.

2. Policies aiming to ensure the protection and promotion of health can assume a high priority and visibility in the actions of progressive political forces and governments, showing that real change is possible, that living conditions can be improved and that wider social consensus and political alliances can be developed on this basis.

3. In post-conflict societies there are immediate, specific health needs, that have to be addressed by governments, political forces and civil society. Action in these fields creates opportunities for a ‘politicisation’ of health demands that can be framed in terms of broader agendas for health reform, also associated with the expansion of welfare systems.

4. In all countries health policies have to be renewed. Neoliberal policies have introduced cuts and privatisation, leading to greater health and social inequalities. The recognition and satisfaction of old and new health needs and the reconstruction of appropriate public health systems requires a rethinking of public policies, welfare systems, participatory practices, solidarity initiatives, with a global approach to health. A collective effort of imagination is needed to develop political projects that may envision health at the centre of a better society, founded on peace, social justice, equality and freedom.

Chiara Giorgi, Sapienza University of Rome

[1] Constitution of the World Health Organization in Basic Documents, 49nd edition, WHO, 2020; M. Cueto, T. Brown ed E. Fee, The World Health Organization. A History, Cambridge, 2019; N. Dentico. E. Missoni, Geopolitica della salute. Covid-19, OMS e la sfida pandemica, Soveria-Mannelli, 2021.

[2] W. Beveridge, Social Insurance and Allied Services, London, 1942, p. 171.

[3] P. Rosanvallon, La società dell’uguaglianza, Roma, 2013, p. 202.

[4] P. Costa, Civitas. Storia della cittadinanza in Europa. L’età dei totalitarismi e della democrazia, vol. 4., Roma-Bari, 2001, p. 430.

[5] W. Beveridge, Social, cit., p. 6.

[6] Ivi, pp. 7 ff.

[7] Ivi, pp. 173, 183.

[8] Ivi, p. 158.

[9] A. Bevan, Il socialismo e la crisi internazionale, Torino, 1952, p. 96 (In place of Fear, London, 1952).

[10] G. Rivett, From cradle to grave. Fifty years oft he NHS, London, 1988; C. Webster, National Health Service. A Political History, Oxford, 2002; S. Cohen, The NHS. Britain’s national health service, 1948-2020, Oxford, 2020.

[11] In the autumn of 1946, the first post-war conference of Italian hygienists was held in Florence with over 230 members, including doctors and representatives of health institutions. Here Giovanardi explained the proposal of the Health Council, inviting «a demolition […] of the current system» and proposing a greater financial intervention by the State in the delivery of healthcare, to be carried out through the use of general taxation, with an explicit reference to the Beveridge Report in the UK (see Atti del congresso degli igienisti italiani, Firenze, 10-13 ottobre 1946, Roma, 1947; A. Giovanardi, Riforma dell’ordinamento sanitario, in “Notiziario dell’Amministrazione Sanitaria”, n. 8, 1947).

[12] See M. Luciani, Il diritto costituzionale alla salute, in “Diritto e società”, n. 2, 1980, pp. 770 ff.

[13] C. Tripodina, Articolo 32, in Commentario breve alla Costituzione, Padova, 2008.

[14] Giovanni Berlinguer was a University professor and politician, brother of Enrico Berlinguer, head of Italy’s Communist Party. Among his works see La salute nelle fabbriche, Bari, 1969; Psichiatria e potere, Roma, 1969; Medicina e politica, Bari, 1973; Malaria urbana. Patologia delle metropoli, Milano, 1976; Una riforma per la salute. Iter e obiettivi del Servizio sanitario nazionale, Bari, 1979; Gli anni difficili della riforma sanitaria, Bari, 1982; Etica della salute, Milano, 1994; La salute tra scienza e politica. Scritti (1984-2011), Roma, 2016; see also F. Rufo (ed), La salute è un diritto. Giovanni Berlinguer e le riforme del 1978, Roma, 2020.

[15] Giulio Macaccaro had been a partisan, was professor of Medical Statistics and Biometrics, founder in 1976 of the association “Medicina democratica, movimento di lotta per la salute”. See G.A. Maccacaro, Per una medicina da rinnovare. Scritti 1966-1976, Milano, 1979.

[16] Laura Conti had been a partisan, was a doctor and politician, and later became one of the founders of Italian environmentalism; among her writings see Che cos’è l’ecologia. Capitale, lavoro e ambiente, Milano 1977.

[17] Ivar Oddone had been a partisan, was a doctor, professor of occupational psychology, and became the major expert of occupational medicine in Italy.

[18] Franco Basaglia was the greatest innovator in the field of mental healthcare, founder of “Psichatria democratica” in 1973; his name is linked to the Basaglia law (n. 180 of 1978) for the reform of psychiatry which led to the closure of asylums in Italy. See F. Basaglia, L’istituzione negata. Rapporto da un ospedale psichiatrico, Torino, 1968; J. Foot, The man who closed the asylums. Franco Basaglia and the revolution in menthal health care, London, 2015.

[19] See C. Giorgi, I. Pavan, Le lotte per la salute in Italia e le premesse della riforma sanitaria. Partiti, sindacati, movimenti, percorsi biografici (1958-1978), in “Studi storici”, 2, 2019, pp. 417-455; Storia dello Stato sociale in Italia, Bologna, 2021.

[20] See C. Giorgi, La sanità da riscoprire. Le radici politiche del Servizio Sanitario Nazionale in A. Mastrandrea, D. Zola (eds), L’epidemia che ferma il mondo. Economia e società al tempo del coronavirus, Roma, 2020, https://sbilanciamoci.info/lepidemia-che-ferma-il-mondolebook-di-sbilanciamoci/; La traiettoria di una sanità pubblica e universale, «L’antivirus. Dialoghi oltre la quarantena», 10, aprile, http://lantivirus.org/la-salute-in-tempi-di-emergenza-e-in-tempi-di-normalita/.

[21] S. Fleury, A.M. Ouverney, Política de saúde. Uma political social, in L. Giovanella, S. Escorel, L.V.C. Lobato, J.C. Noronha, A.I. de Carvalho (eds), Políticas e sistemas de saúde no Brasil, Rio de Janeiro, 2008.

[22] PAISM was born in 1983 thanks to the collaboration between the women’s movement, health professionals and officials of the Ministry of Health. Its purpose is to implement actions aimed at protect women’s health, considered not only in her reproductive functions, but in her integrity and in all phases of her life. PAISM was born from the need to fill the institutional void regarding women’s health, in the broader context of the process of democratization of Brazilian society. See V. Ribeiro Corossacz, Il corpo della nazione, Roma, 2004.

[23] See A. Cohn, Caminhos da reforma sanitária, Lua Nova: Revista de Cultura e Política, n. 19, 1989, pp. 123 ff; A.C. Laurell, Social Analysis of  Collective Health in Latin America, in “Social Science & Medicine”, n. 28, 1989, pp. 1183 ff; J.S. Paim, Almeida Filho, N., Collective health: a “new public health” or field open to new paradigms?, in “Revista de Saúde Pública”, n. 32, 1998, pp. 299 ff; C.F. Guimarães, O Coletivo na Saúde, Porto Alegre, 2016; C. Bodini, Movimenti sociali e salute: una ricerca-azione partecipata, Tesi di Dottorato in Scienze mediche generali e scienze dei servizi, Università degli studi di Bologna, ciclo XXX, 2018.

[24] Constituição da República Federativa do Brasil, Senado Federal, Brasília, 1988; Ministério da Saúde, Secretaria de Políticas de Saúde, Políticas de Saúde. Metodologia de Formulação, Ministério da Saúde, Brasília, 1998.

[25] Ministério da Saúde, Conselho Nacional de Secretários Municipais de Saúde, O SUS de A a Z: garantindo saúde nos municípios, Brasília, 2005; Ministério da Saúde, Política Nacional de Promoção da Saúde, 3° ed., Brasilia, 2010.

[26] S. Fleury (ed.), Saúde e Democracia: a luta do Cebes, São Paulo, Lemos Editorial, 1997; Ead., Dual, Universal or Plural? Health care models and issues in Latin America: Chile, Brazil and Colombia, in C. Molina, J. Del Arco (Eds.), Health Services in Latin America and Asia, Washington, D.C, 2001.

[27] V. Garrafa, C. Cornelli, Berlinguer e la politicizzazione dell’agenda bioetica internazionale, in “Bioetica”, n. 4, 2015; G. Berlinguer, S.F. Teixeira, G.W.S. Campos, Reforma sanitaria. Italia e Brasil, Sao Paulo, 1988.

[28] S. Rutherford, S. Saleh, Rebuilding health post-conflict: case studies,reflections and a revised framework, “Health Policy and Planning”, 2019, n. 3. The focus of this analysis is on the cases of Cambodia, Afghanistan, and Mozabique.

[29] C. Siriwardhana, K. Wickramage, Conflict, forced displacement and health in Sri Lanka: a review of the research landscape, “Conflict and Health”, 2014.

[30] How to affirm the Charter of the Social Contract (art. 30): All persons have the right 1. to personal security in a peaceful and stable society; 2. to free and compulsory primary and secondary education; 3. to work, social security, health, adequate housing; 4. to protect the motherhood and maternal and pediatric care; 5. to adequate health and social care for the disabled, the elderly and those with special needs. See http://peaceinkurdistancampaign.com/resources/rojava/charter-of-the-social-contract/.

[31] M. Knapp, A. Flach, E. Ayboga, Revolution in Rojava. Democratic Autonomy and Women’s Liberation in Syrian Kurdistan, London, 2016; K. Tatort, Democratic Autonomy in North Kurdistan. The Council Movement, Gender Liberation, and Ecology in Practice, Norway, 2013; E. Aretaios, The Rojava Revolution, https://www.opendemocracy.net/en/north-africa-west-asia/rojava-revolution/.

[32] AA.VV. Rojava una democrazia senza Stato, Milano, 2017, p. 176.

[33] Ivi, p. 177.

[34] See Rojava information center, Standing alone: medical, political and social strategies for supporting war wounded individuals in NES, march 2021.

[35] Un Ponte per, North East Syria 2021 Health strategy, working paper, january 2021. I thank Luca Magno of “Un Ponte” per for the information, materials and insights he has provided.