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Inequities, Partecipation and democracy. The Iran case

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Ambrogio Manenti


1. Inequities in the world
The "widening equity gap" with a redistribution of wealth from public to private, from labour to capital and from poor to rich is a phenomenon generally spread all over the world.
Below are described examples of inequities mentioned by WHO in the frame of the Commission on Social Determinants of Health (WHO 2008).
• The benefits of the economic growth that has taken place over the last 25 years are unequally distributed. In 1980 the richest countries, containing 10% of the world's population, had gross national income 60 times that of the poorest countries, containing 10% of the world's population. By 2005 this ratio had increased to 122.
• International flows of aid - grossly inadequate in themselves, and well below the levels promised - are dwarfed by the scale of many poor countries' debt repayment obligations. The result is that, in many cases, there is a net financial outflow from poorer to richer countries - an alarming state of affairs.
• The trend over the last 15 years has been for the poorest quintile of the population in many countries to have a declining share in national consumption.
• Gender biases in power, resources, entitlements, norms and values, and the way in which organizations are structured and programmes are run damage the health of millions of girls and women. The position of women in society is also associated with child health and survival - of boys and girls.
Considering the developed countries, some authors, mentioning the study of the Bank for International Settlement, affirm that in the last 25 years an important part of wealth produced in the main industrialized countries has been transferred, in a growing proportion, from salaries to profits.(The % of the GDP, classified as profit which was 23% in 1983 has increased at 31% in 2005 while symmetrically the % related to working class salaries has decreased from 77.8% to a bit more than 68%). (Revelli 2011)
Stiglitz, Noble Prize in Economics in 2001, referring about inequalities in America recently wrote: "The upper 1 percent of Americans are now taking in nearly a quarter of the nation's income every year. In terms of wealth rather than income, the top 1 percent control 40 percent. Their lot in life has improved considerably. Twenty-five years ago, the corresponding figures were 12 percent and 33 percent... While the top 1 percent have seen their incomes rise 18 percent over the past decade, those in the middle have actually seen their incomes fall. For men with only high-school degrees, the decline has been precipitous-12 percent in the last quarter-century alone. All the growth in recent decades-and more-has gone to those at the top". Among the several reasons for this, Stiglitz mention the economic globalization:" The rules of economic globalization are likewise designed to benefit the rich: they encourage competition among countries for business, which drives down taxes on corporations, weakens health and environmental protections, and undermines what used to be viewed as the "core" labor rights, which include the right to collective bargaining. Imagine what the world might look like if the rules were designed instead to encourage competition among countries for workers. Governments would compete in providing economic security, low taxes on ordinary wage earners, good education, and a clean environment-things workers care about. But the top 1 percent don't need to care." (Stiglitz 2011).
Inequities in health
The inequities, described in the economic field, are also strongly present in health:
• The infant mortality rate (the risk of a baby dying between birth and one year of age) is 2 per 1000 live births in Iceland and over 120 per 1000 live births in Mozambique;
• The lifetime risk of maternal death during or shortly after pregnancy is only 1 in 17 400 in Sweden but it is 1 in 8 in Afghanistan.
However the health inequities can be also found within countries.
• In Bolivia, babies born to women with no education have infant mortality greater than 100 per 1000 live births, while the infant mortality rate of babies born to mothers with at least secondary education is under 40 per 1000.
• Life expectancy at birth among indigenous Australians is substantially lower (59.4 for males and 64.8 for females) than that of non-indigenous Australians (76.6 and 82.0, respectively).
• Life expectancy at birth for men in the poor Calton neighbourhood of Glasgow is 54 years, 28 years less than that of men in the rich Lenzie area, a few kilometres away.
• The prevalence of long-term disabilities among European men aged 80+ years is 58.8% among the lower educated versus 40.2% among the higher educated. (WHO 2008).
Health equity depends vitally on the empowerment of individuals to challenge and change the unfair and steeply graded distribution of social resources to which everyone has equal claims and rights. Inequity in power interacts across four main dimensions - political, economic, social, and cultural - together constituting a continuum along which groups are, to varying degrees, excluded or included. (WHO, 2008)


2. Welfare System to redistribute wealth and to ensure the fulfillment of social rights
Considering the enormous inequities described, appropriate policies which could promote equity through a proper economic development are indispensable.
However, equally important are redistributive policies related to the social protection.
Social protection system de facto means welfare system under the main responsibility of the state. The welfare state has been "the most extraordinary invention of social engineering of the last 150 years." (Pennacchi, 2008).
Through it a social protection, before delivered by church, extended family and feudal traditions, was gradually institutionalized under state main responsibility.
Funds collected through a fair tax system (people paying proportionally to their wealth) are utilized to deliver effective public services, equal for everybody, which can ensure universal health, education, social protection coverage.
Welfare states have therefore contributed to the development and wellbeing of millions of people all over the world redistributing the wealth and promoting social rights.
The Commission on Social Determinants of Health (CSDH) report (WHO 2008) highlights the need to guarantee Universal social protection systems across the life course. "It is important for population health in general, and health of lower socioeconomic groups in particular, that social protection systems are designed such that they are universal in scope. Universality means that all citizens have equal rights to social protection. In other words, social protection is provided as a social right, rather thank given to just the poor out of pity." (WHO, 2008)

Crisis of Welfare State
Unfortunately subsequent to an important development after the second world war, welfare system in the last 20-30 years has started a critical phase. "Welfare system" has even become an inconvenient expression. "The global development policy was dominated by neo-liberal macroeconomic and social policies...these policies manifested as structural adjustment programs that sought to reduce budget deficits through devaluations of the local currency and cuts to public spending in all sectors, including health, education and transport."
The globalization and the "deregulation of international capital flows and trade has considerably narrowed the scope of governments to pursue expansionist and redistributive policies, forcing all governments to cut social and public expenditures and deregulate labour markets in order to make their countries competitive." (Navarro et al., 2004)

In addition, nowadays the difficulties of welfare system all over the world are increased by the current financial and economic crisis.
Over the period 2008-2009, the world experienced its worst financial and economic crisis since the Great Depression of the 30s. Given the fragility of the economic recovery and the uneven progress in major economies, social conditions and expected to recover only slowly. The increased levels of poverty, hunger and unemployment will continue to affect billions of people for years to come.
Meanwhile, austerity measures in response to high government debt in some advanced economies are also making the recovery more uncertain and fragile. Increased pressure for fiscal consolidation and new pressures in response to such debt have severely limited fiscal and policy space in developed economies, and many developing countries, especially those under International Monetary Fund programmes, are also under pressure to cut public expenditure, undertake austerity measures, reduce the scope of government action and further liberalize labour markets. (UN, 2011)

The effects on health of an economic downturn can be rapid and dramatic. (Marmot and Bell, 2009)

Therefore, considering the overall situation, the following questions is necessary: how should the welfare system be preserved where existing and expanded where it is weak in order to assure a redistribution policy and the fulfillment of social rights - health, education and social protection in such a difficult context?



3. Human development, a concept promoting social rights and substantive freedoms
The increasing inequities are also related with the lack of adequate redistributing policy by several countries which do not give priority to the human development.
Human development is different from economic growth and great achievements are possible even without fast growth. The first Human Development Report (UNDP, 1991) pointed to countries like Costarica, Cuba and Sri Lanka, which had attained much higher human development than other countries at the same income levels. These achievements were possible because growth had become decoupled from the progress in other dimensions of human development.
According to the 2010 Human Development Report (UNDP, 2011) the Brazilian State of Ceara' and the Indian State of Kerala have demonstrated the rapid gains possible through extensive public provision of health services. Many interventions in developing countries to reduce mortality and improve health are not costly.
A little correlation exists between health improvement and economic growth, particularly in low Human Development Index countries. Large expansion in health as well as in education became feasible even for developing countries. In health once-costly innovations became available at low cost. In education even poor countries could afford to expand the key inputs, teachers and buildings, since neither has to be imported from abroad. (UNDP 2011)
Also in the middle income countries the overall development approach has focused more on economic growth than human development. According to the Human Development Index 2010 there are several examples of middle income countries (e.g. Russia, China, Thailand, Turkey, South Africa and Iran) with health and education components less developed than the economic one.
Therefore, it is important to develop the human development approach where the potential synergy between economic and social development could actually occur.
For this, politics and policies are essential variables to be taken into consideration.
4. Politics and policies supporting welfare state and health

According to the literature all best examples of good welfare state, health and education systems, independent from their level of development, are found in countries with long history of social democratic government (Scandinavian countries, Costarica, Sri Lanka, State of Kerala in India) or countries belonging to the "real socialism" regime (Cuba and China).
Some authors examined the complex interactions between political traditions, redistributive policies and public health outcomes in order to find out whether political traditions have been associates with systematic patterns in population health overtime.
In the next paragraph an important work of Navarro is summarized (Navarro et others, 2006)

Political traditions and redistributive policies. A study on European countries.

Within the group of OECD countries examined in this study( Navarro et others, 2006), those mainly governed by social democratic parties for the majority of the period under study (1950-2000) are Sweden (for 45 years), Norway (39 years), Denmark (35 years), Finland (32 years), and Austria (31 years).
The social democratic parties in these countries have historically been committed to redistributive policies (the average Gini coefficient in this group over the last 10 years of the study period was 0•225).They have also provided universal health care coverage, and social benefits to all citizens (the average public social expenditure in this group was 30% of gross domestic product (GDP), and the average public health care expenditure over the last 10 years of the study period was 7•2% of GDP).The public social policies of these parties have included policies designed to encourage a high proportion of adult men and women to gain employment, generous non-means-tested social transfers and social services, including family-oriented services (such as child care and home care) aimed at facilitating the integration of women into the labour force.(On average in this group, excluding Austria, 82% of women are in the labour force; for Austria it is 48%.) Thus, compared with the other four political traditions, the social democratic parties have tended to introduce policies that support women's health and wellbeing, such as unemployment compensation for single mothers, active labour market spending, women's labour force participation, low crime, participation of women in government, child care, early child education, paid maternity leave, and home care services.

Within the scope of this investigation, the countries that have been mainly governed by Christian democratic parties, or conservative parties in the Judeo-Christian tradition, for most of the period from 1950 to 2000 are Italy (for 41 years), Netherlands (41 years), West Germany (37 years), Belgium (35 years), and France (29 years).
These parties have been less committed to redistributive policies than the social democrats, and the average Gini coefficient within this group was 0•306. However, they
do provide generous social transfers to older citizens, funded mainly by payroll taxes through social security systems (the average public social expenditure was 28% of GDP, and the average public health care expenditure was 6•4% of GDP). These parties provide universal health care services (mostly publicly funded), although they do not emphasise family-oriented services such as child care and home care; on average, only 62% of women in these countries was in the labour force.

Countries mainly governed between 1950 and 2000 by liberal parties, or conservative parties of a liberal persuasion, are the UK (for 36 years), Ireland (for 35 years), Canada (for 31 years), and the USA (for 28 years).13-16 The liberal parties have not traditionally had a strong commitment to redistributive policies (the group average Gini coefficient was 0•320; and the Gini coefficient for the USA was 0•372). Neither do they provide universal social services (except universal health care, which is provided in all but the USA). Most social services benefits in these countries are means tested, and public social expenditures are much lower than in the countries governed by social democratic and Christian democratic parties; the average public social expenditure was 24% of GDP, and the average public health care expenditure was 5•8% of GDP.

The last group of countries was governed for most of 1950-2000 by conservative dictatorships (Spain's dictatorship lasted for 25 years during the period of this study
and Portugal's for 24 years) or very authoritarian conservative regimes (Greece's regime lasted for 9 years during the period under study). Until the late 1970s, when democracy was established in these countries, they had underdeveloped welfare states with very low public transfers and poor public services, and had the most unequal income distribution of the countries under investigation (the average Gini coefficient for the group
was 0•423). Public social expenditures were very low (the average social expenditure at the end of each dictatorship, some time in the 1970s, was only 14% of GDP, and the average public health care expenditure was only 4•8% of GDP). Since the establishment of democracy, however, the welfare states of these countries have developed considerably, especially during the periods when they were governed by social democratic parties. Current levels of public social expenditure in these countries are now close to those in countries of the liberal tradition (in 2000, the average public social expenditure was 20% of GDP, and the average public health care expenditure was 5•8% of GDP).

Type of government Coefficient Gini Public/social exp. Public/health exp.

Social democratic 0.225 30% of GDP 7.2% of GDP
Christian democratic 0.306 28% 6.4%
Conservative 0.320 24% 5.8%
Dictatorship 0.423 14% 4.8%

Political traditions and health outcomes

The study findings show that redistributive policies are positively associated with health outcomes.
The analysis reveals a clear, robust, and significant negative correlation between, on the one hand, cumulative years of government by pro-redistributive parties and resulting
level of income redistribution and, on the other, infant mortality. Long periods of government by pro-redistributive parties are associated with low infant mortality.
The analysis also showed that in the years for which there are relevant data there has been a negative correlation between income inequality and life expectancy, both women and men. An important finding is that the implementation of policies aimed at reducing social
inequalities seems to have a salutary effect on population health, which would explain why health indicators such as infant mortality are better in countries that have been
governed by pro-redistributive political parties. (Navarro et others, 2006)

5. Role of civil society in keeping and strengthening the welfare state
If the role of governments is essential for the welfare state development, the involvement of civil society is equally important. In the recent years, people are generally more and more aware about their rights. "Nothing about me without me" is a known slogan of the ‘modern' commitment of people.
The actors of civil society can promote the participation of communities in the decision making process related to the service delivery.

More in general, historically, the welfare state has been the result of social struggle and class confrontations, where the trade unions, the people' association, active sectors of the society and representatives of the weakest and vulnerable groups have played an important role of promotion of social, education and health services, widening democratic spaces and encouraging a policy inspired to social rights. Public services of good quality and universal coverage, social benefits, a specific attention to the population needs have been the result of the growing power of the workers' and citizens' organizations.
The welfare state does not therefore represent only the sum of social institutions and public budget, but also an important part of the power balance within the different components of the society.
"Public welfare is not a question of good intentions, good will or high morale (or corporate social responsibility, as somebody names it), but of power relations, of the balance of power between labour and capital, between market forces and civil society" (Walh, 2007).
According to Walh, the social pact which have been marking the recent history, particularly in the western society, is now broken and is somehow the cause of the worsening conditions of the workers and weak sectors of the society.
This was made possible only because great parts of the working class had been able to shift the balance of power between labour and capital through a number of confrontations and hard class struggles during the first part of the 20th century (including the Russian revolution). It was in other words the confrontational struggles of the previous period, as well as the still existing organisational strength, which made it possible for the trade unionists of the social partnership era to achieve what they did through peaceful negotiations. Thus, we face the paradoxical situation, that the ideology of the social pact, which also became the ideology of the welfare state, in the long run undermined the power basis on which the same welfare state was developed!... The post-war Keynesian economic model ran into increasing problems. Stagnation, inflation and profit crises became prevalent. Spurred by these international economic crises, market forces went on the offensive and the current era of neo-liberalism started. The politics of the social pact thus culminated in the 1970s. After that, the capitalist forces changed their strategy in order to restore profitability, withdrawing gradually from the social pact and introducing more confrontational policies against labour...The trade union movement was taken by surprise by this development. The shift from consensus to confrontation on the side of capital was incomprehensible within the consensus-oriented social pact ideology of the labour movement. The breakdown of the historic compromise therefore also led to a political and ideological crisis in the social democratic parties and in most of the labour movement. With a depoliticised and passive membership, and an increasingly self-recruiting leadership which was moving into the elite of society, social democratic parties rapidly adapted to the dominant neo-liberal agenda, although in the form of softer alternatives than the original right wing version...Rather than to be seen as a step towards a more fundamental social emancipation, the class compromise, and its true-born offspring, the welfare state, gradually became the end of history. (Walh, 2007)
However, beside this interpretation, other aspects should be considered to explain the weaknesses of the people active and critical role and involvement in the processes of development of the societies defending and strengthening the welfare state.
For instance Franco Cassano (Italian sociologist), mentioning Adorno and the Frankfurt School approach, describes another relevant point.
"The concrete humanity seems blissfully caught by the thousand seductions of the mass culture and production. In other words, there is a heavy obstacle between the human beings and their emancipation and this is their weakness, which push them to choose a lower level and less conscious life and more closed in the reproductive mechanisms of a social system which offer a quantity of goods and stimulus absolutely unknown in the history. The linear and more simple path of the consumers contrasts the autonomous human being able to self managing and protagonist of the public sphere. It is moving in the limited area of the comparison among different goods and it has, as only programme, that one of growing its own private interest". (Cassano, 2012)
However, on this aspect the discourse should be further elaborated.
7. The case of Iran
Health: partial right

The health system in Iran, reformed after the 1979 Islamic Revolution, was organized
on the principles of the Conference of Alma Ata (International Conference on Primary
Health Care held in Alma Ata in 1978, ex-USSR): accessibility to health services for
the entire population, importance of the Primary Health Care (PHC), focus on prevention,
attention to disadvantaged groups and isolated communities, development of community
health workers .
The economic and social development of the country and the health care system centered on the PHC have resulted in improved health status (Child Mortality under 5 years
fell from 73 per 1000 in 1990 to 31 per 1000 in 2009; Maternal Mortality fell from 150
per 100,000 in 1990 to 30 in 2008; life expectancy increased from 63 in 1990 at age
72 in 2008) [2].
Despite this relatively advanced situation compared to the situation in the Middle East
region, since the nineties, under the influence of neo-liberal tendencies which had
developed during the previous decade in various parts of the world, the private sector
became increasingly important also in areas traditionally public. While the public health
services in urban areas have been competing with the private services, they have been too
slow in readjusting policies and strategies to changes that were, meanwhile, occurring in
the country. In fact, the demographic profile, with a wide portion of young population (a phenomenon favored by the baby boom during the Iran-Iraq war in 1980-1988) and the epidemiology, characterized predominantly by infectious diseases, have been changing over the years, foreshadowing a situation typical of middle income country with progressively more and more older population and more chronic non-communicable diseases.
However, despite these ongoing changes in the Iranian society, the public health system
Health situation in Iran has not been evolving according to the population needs and the attitude that prevails in part of "people in charge" and managers is often to glorify the past (e.g. describing the achievements of PHC in rural areas) and to live on their laurels while an improvement for access and quality of health services would be necessary right away.


According to estimates by the Ministry of Health and Medical Education, more than
50% of Health Expenditure is currently represented by out-of-pocket. This high percentage of direct financial contribution of users to health care costs leads to a serious
situation for 2.5% of the Iranian population facing a catastrophic health expenditure ,
which makes every year 1% of the population to become poor (MOHME 2009). The use of private PHC services and hospitals (especially in big cities) and the contribution to the costs for specialized out patients services and hospital care in the public sector are the main reasons for the high direct expenditure by the population.


The 5th Development plan (2011-2015) includes as a goal the reduction of out of pocket expenditure but it does not indicate how to do it.
In the last 30 years, the PHC has not been equally and adequately developed throughout
the country. Particularly the urban public PHC services are not able to meet the health
needs of the population. In the cities, where 2/3 of the Iranian population lives, users
make extensive use of private services for simple health problems. The family doctor
does not exist in the urban health centers but only in rural areas where, by the way, the
high number of patients per doctor (ratio is approximately 1 doctor for 4000 inhabitants)
influences the quality of services for the limited time available for each patient and not
allowing home visits to patients who need it.
The PHC should be seriously re-adapted to the demographic and epidemiological
changes, but this is happening only partially.
For example, community health workers "Behvarz", as the cornerstone of the PHC
system in rural areas, continue to perform duties mainly related to the prevention of
infectious diseases with priority given to vaccination, personal hygiene, water and sanitation rather than to also implement activities of health promotion related to the risks
of non-communicable disease such as smoking, inadequate diet, sedentary lifestyle and
alcohol use (Malekafzali, 2008).
As for hospitals, there is coverage across the country with public and private facilities
(the private ones representing the 15 % of total). However, the co-payment required
for the users in public hospitals are high and the quality of services is sometimes poor.
Furthermore, in some health fields there is a tendency to "medicalize" needs that would
require another kind of answers. A striking example is the problem of births by caesarean
section that shares at least 42% of total births in the country, according to the data of
2005 [7] (The rate seems higher than this according to recent survey done by Ministry
of Health and Medical Education in 2009).


Welfare System and Social Protection

In general, Iranian institutions foster leadership ambitions in the region. The rhetoric
about it is sometime redundant in official events. However, in social and health sectors,
the ambitions of leadership are often backed by a situation certainly more advanced
and developed than other countries in the region. The main health indicators, the
rural PHC system, the production of medicines and vaccines, the health and social services for drug addicts and HIV patients are only some examples where Iran is better
than others.

However, the level of "human development" of Iran is not particularly good. Considering, for example Iran's position in the Human Development Index (HDI) , in 2007 the country is only the 88th place out of 182 countries (UNDP, 2009). In addition, while for the GDP per capita, which measures economic development, Iran is at the 71st place, for life expectancy, which indicates the health status, it is only at the 95th . This means that the economy in Iran has been developing more quickly than health.
In fact, the welfare system in Iran, although relatively well-structured after the Islamic
Revolution (1979) that glorified equity and social rights, has shown later precise limits
on access and quality not only in health but also in education. Private schools are well
developed and compete for quality with the public schools attracting large parts of the
middle class and popular sectors.

Social exclusion and civil society

Social exclusion is the results of various and complex factors. The followings are
some of the mechanisms recognized to facilitate people exclusion: centralism, decision
making according to a strict hierarchy, sectoralism and welfarism.
Although in Iran the family plays an important role in the management of the weakest
groups of the society, the approach of several institutions tends towards exclusion
and segregation. An adequate system of social protection is lacking. Asylums for mental
ill patients and special schools for disabled children are examples of this approach
which do not promote integration and inclusion of vulnerable groups within the society.
Considering the women's rights, situation is controversial. In fact, while on one hand,
Iran has achieved unquestionable successes in education by increasing access to education of women (e.g. women university students are increased from 27%in 1990 to 50% in 2002) (UNESCO, 2006), women remain non-influential in the areas of decision-making (e.g. only 2.8% of parliamentarians are women) (UN, 2009). In
addition, the legal framework is controversial (e.g. Iran has not signed the Convention
on the Rights of Women: United Nations convention on the Elimination of All Forms
of Discrimination against Women but it has adopted the charter: "Law of women's rights
and responsibilities in I. R. Iran" in 2007).
Complex and problematic is the situation of young people. For instance, there is an
evident gap between level of education (high rates of schooling) and opportunity of work
(high levels of unemployment). Drug addiction, marginalization and violence are some
of the problems arising from the lack of promising perspectives for the future. Specific
measures of reduction of vulnerability and increasing protection should be taken.
A proper managerial approach to the problems of vulnerable groups would require a
collective effort involving all sectors of society particularly public institutions and nonprofit area. Unfortunately, NGOs and civil society associations are sometimes negatively perceived by public institutions and the role of non-profit sector is limited both in the management of services and in the support to marginal people.

Way forward

Iran achievements in the health sector during the last 30 years should not hide the shortcomings.
All the main problems which are affecting people due to lack of access and
quality of health care deserve to be addressed with a proper policy promoting universal
coverage, PHC and family practice and patient's rights.
It is therefore important for Iran to invest more in health and in the sectors which are
representing relevant social determinants of health such as education and social sectors
and to reach a universal protection as social right through a solid and generous welfare
system for enabling healthy living for all across the life course.
The welfare system should be "a welfare system mix" with a specific role of the
NGOs and civil society. The non-profit sector (which is no private and no public)
would allow dealing effectively with the complex problems of the most vulnerable
sectors of population such as chronically ill, disabled, marginalized youth, elderly and
others applying approaches more human-centered, more flexible, less expensive and
contributing to reduce inequity and social exclusion.
The approach towards people should be holistic taking into account their physical, emotional and social concerns, their past and their future, and the realities of the world in
which they live.
For all this, the link between I.R. Iran and international partners should be strengthened
which is a precondition for any development in an interdependent and globalized world.




6. Conclusions

Difficult conclude on a so complex thematic. I would propose short conclusions offered by the quoted authors of this article.

1. On the policies of governments towards the economic and financial crisis.

A key conclusion of this Report is that countries need to be able to pursue countercyclical policies in a consistent manner. Such policy space should be enabled by changing the fundamental orientation and nature of policy prescriptions that international organizations impose on countries as conditions for assistance.
It is essential that Governments take into account the likely social implications of their economic policies. It has been shown, time and again, that economic policies considered in isolation from their social outcomes can have dire consequences for poverty, employment, nutrition, health and education, which, in turn, adversely affect long-term sustainable development. The disconnect between economic policies and their social consequences can create a vicious circle of slow growth and poor social progress. Universal social protection systems and active employment generation programmes should become permanent measures, not merely temporary components of national crisis response measures.
Increasing expenditures to expand social protection and improve access to education and health services will help ensure more inclusive development with stronger domestic demand and a more solid foundation for future growth. (UN, 2011).

2. On the social battle to undertake

In order to oppose an inadequate social model in the interest of the great majority of the society in long term, the economic, political and social interests which inspire the attack to public services and welfare state should be contrasted. Structures and relationships of power should change. A considerable shift in the balance of power can only be achieved through a broad interest-based mobilisation of trade unions, social movements and other popular organisations and NGOs which is strong enough to confront the corporate interests and push them on the defensive. An ever broader part of our societies are the victims of the current neo-liberal offensive, and it is exactly these affected social groups which will have to be united in new, untraditional alliances. Structural reform such as the tax on the financial capital, the control of capitals, the increased taxation to multinational companies, the local management of the natural resources and progressively a more democratic vision of the economy should be the initial moment and the direction of the social future battles.


3. Sulle esperienze avanzate del passato

I nostri studi supportano l'ipotesi che le ideologie politiche dei partiti di governo influenzano alcuni indicatori della salute della popolazione. La nostra analisi stabilisce un legame empirico tra opzioni politiche e programmi sociali, mostrando che i partiti politici con ideologie egualitarie tendono a sviluppare politiche redistributive. Un importante risultato della nostra ricerca e'che politiche tese a ridurre la diseguaglianza sociale, tali come la promozione del Welfare State e di politiche per il mercato del lavoro sembrano avere un effetto salutare su importanti indicatori di salute come la mortalita' infantile e la speranza di vita. (Navarro, 2006)

E' questo il lascito piu' importante, da tradurre per il futuro, del modello sociale europeo: diffuse forme di participazione, intense base morali della convivenza, ampi diritti di cittadinanza, sistemi fiscali progressivi generano il contesto essenziale per una democrazia funzionante, e tale contesto crea a sua volta le condizioni per una convergenza non conflittuale delle aspettative dei cittadini e per il loro operare cooperativo in funzione di una qualche idea del " bene comune". ( Pennacchi, 2008)

4. Su come riformare il Welfare

Si devono riscoprire nella ammistrazione pubblica i caratteri dell'ethos weberiano e nel dipendente pubblico quelli del civil servant, rendendo cosi' possibile tornare a fare leva, anche per aumentare la produttivita', sulle complesse risorse motivazionali delle persone che vi lavorano. Riscoprirne l'ethos permette di neutralizzare l'idea che per riformare la pubblica ammistrazione sia importante solo "spostarne il perimetro" - rimanendo indifferenti a cio' che succede al di qua e al di la' del perimetro stesso - e al tempo stesso di sperimentare adeguate forme di partnership tra pubblico e privato. ( Pennacchi, 2008)

5. Sull'atteggiamento delle persone piu' impegnate della societa' civile

La lezione che ricaviamo e' molto semplice e forse a questo punto quasi scontata: dobbiamo sperare di avere grande forza morale, ma questa forza non deve mai portarci a liquidare la nostra capacita' di parlare con tutti e di provare a capirne le ragioni, a dimenticare l'enorme importanza che ogni essere umano possiede ai propri occhi, a prescindere dal suo grado di perfezione. Il pensiero dell'"emancipazione"non deve abbandonare la sua radicale contrapposizione al pensiero conservatore, ma deve saper rinunciare a quel malinteso senso di superiorita' che gli impedisce di apprendere dal rapporto piu' lucido che spesso il suo avversario intrattiene con la realta'. Per non precipitare nel disastro, deve imparare a fare i conti con la fragilita' che caratterizza l'essere umano e non guardarla dall'alto. Non bisogna lasciare al conservatorismo la confidenza con la debolezza dell'uomo...La fraternita' va praticata subito e costantemente, perche' le vie di un cambiamento o sono praticate da un gran numero oppure non sono. Uno dei rischi piu'gravi oggi e' quello di rifugiarsi in una sorta di repulsione antropologica nei riguardi delle plebi dominate dal consumismo sotto l'egemonia seduttiva dei piazzisti. Bisogna come hanno fatto i migliori, tenere fermo il fine, ma saperne riconoscere la presenza anche laddove esso appare mutilato o sfigurato..Aggirare la propria supponenza di ceto e' un compito difficile ma ineludibile, se non si vuole essere scavalcati dalle prossime rivoluzioni antropologiche lasciandole alla spregiudicatezza dei Grandi Inquisitori che verranno. (Cassano 2011)

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Cassano, F. L'umilta' del male. Laterza.Editore. 2011

Farzin, A. UN inter-agency welfare system initiative. Gaps and issues in Iran's welfare system (first draft - Unedited). 2010. Tehran

Malekafzali, H., Primary health care Success and Challenges in Iran, WHO-Iran Quarterly Newsletter, Volume 4, Numbers 3-4. 2008. Tehran.

Marandi, S.A., The integration of Medical Education and health care services in Islamic Republic of Iran and its health impacts. The first international conference in partnership with WHO, 1-4 November 2008, Doha

Marmot, M. and Bell, R. How will the financial crisis affect health? 338.BMJ, 2009

Ministry of Health and Medical Education. National Health Account. Structure, links and contribution to the health policy. MOHME. 2009. Tehran.

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Navarro V., Schmitt J., Astudillo J. Is globalization undermining the welfare state? Cambridge Journal of Economics, 28, 133-152. 2004
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By the same authors:      Inequities and the Gelateria Sociale Project 

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Center for urban suffering

The study centre wishes to study the phenomenon of urban suffering, in other words the suffering that is specific to the great metropolises. Urban Suffering is a category that describes the meeting of individual suffering with the social fabric that they inhabit. The description, the understanding and the transformation of the psychological and social dynamics that develop from the meeting of ...

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The Urban Suffering Studies Center - SOUQ - arises from Milan, a place of complexity and economic and social contradictions belonged to global world.Tightly linked to Casa della Carità Foundation, which provides assistance and care to unserved populations in Milan (such as immigrants legal and illegal, homeless, vulnerable minorities), the Urban Suffering Studies Center puts attention on ...


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