Correspondence
The Lancet—University of Oslo Commission on Global Governance for Health (Feb 15, p 630)1 articulates the various global non-health sector influences on health—namely, the global political determinants of health. The recognition of these effects is not new, but articulating a compelling way to refer to them is a useful contribution and will help to shape the future research agenda. The Commission highlights the way in which some actors are able to exert disproportionate levels of influence to serve their interests. We commend the Commission for identifying these serious power disparities in global governance, and illustrating their profound implications for health. The Commission has provoked attention to these political realities and created an important discussion. Yet the Commission’s recommendations, as the companion Youth Commission2 noted, “are likely to be influenced by the same diverging interests and power asymmetries described by the Commission”. We would like to propose a possible path forward. To tackle the global political determinants of health, there is first a need for more rigorous analysis of how national, international, and institutional actors shape and influence the global political determinants of health. The Commission refers to power, but it does not consider the need to better understand empirically how power is expressed in global health governance. The fields of international relations, sociology, and philosophy, however, do apply power as a conceptual lens for understanding how actors behave. While global health scholars led by Gill Walt3 have explored how power is expressed and exercised, power could be particularly useful to understand the global political determinants of health. www.thelancet.com Vol 383 June 28, 2014
There are a number of analytical frames to better understand or investigate power. Robert Dahl 4 proposed power as decision making (ie, A forcing B to do A’s choice against B’s will). Peter Bachrach and Morton Baratz5 argued for the importance of non-decision making (A confines B’s spectrum of possible choices); this has also been called the mobilisation of bias. Steven Lukes6 considered power as thought control (ie, A makes B want A’s choice). Together these three approaches to assess power, be it overt, covert, or latent, present one possible framework. Michael Barnett and Raymond Duvall7 presented another frame based on four approaches to power—namely, compulsory, institutional, structural, and productive forms. These frameworks, or a mix of them, could be a useful place to begin. A greater and more explicit focus on power as a tool for analysis of global political determinants of health can help to illuminate how actors create and exploit disparities to serve their interests. Crucially, a better understanding of power, which is especially important with the rise of non-health and non-state bodies’ influence over the global policy environment within which health systems must navigate, will allow for the design of policies and processes to redress disparities. We declare no competing interests.
*Robert Marten, Johanna Hanefeld, Richard Smith [email protected] The Rockefeller Foundation, New York, NY 10018, USA (RM); and Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK (RM, JH, RS) 1
2
3 4
Ottersen OP, Dasgupta J, Blouin C, et al. The political origins of health inequity: prospects for change. Lancet 2014; 383: 630–67. Gopinathan U, Cuadrado C, Watts N, et al. The political origins of health inequity: the perspective of the Youth Commission on Global Governance for Health. Lancet 2014; 383: e12–e13. Walt G. Health policy: an introduction to process and power. London: Zed Books, 1994. Dahl R. The concept of power. Behav Sci 1957; 2: 201–15.
5 6 7
Bachrach P, Baratz M. Two faces of power. Am Pol Sci Rev 1962; 56: 947–52. Lukes S. Power: a radical view, 2nd edn. Houndmills: Palgrave MacMillan, 2005. Barnett M, Duvall R. Power in global governance. Cambridge: Cambridge University Press, 2005.
The University of Oslo
Commission on Global Governance for Health: what about power?
A platform for a Framework Convention on Global Health The right to health provides the foundation to accelerate recent global health gains, extend them to the most excluded populations, and fortify them against threats beyond the health sector. Yet states often fail to meet their obligations. And the national focus can diminish effectiveness because solutions require global cooperation, from shared financing and capacity building to global norms and accountability.1 An innovative global health treaty—a Framework Convention on Global Health—could establish a right to health for the 21st century. The binding power of law would enhance the ability of civil society advocates to hold governments accountable through courts, parliaments, and the media, while creative incentives and sanctions would encourage compliance. Through international law, the Framework Convention on Global Health would ensure respect for the right to health within other legal regimes, such as trade, investment, and intellectual property—aspects of which might otherwise undermine this right. A treaty could establish the legal framework to achieve the grand convergence in global health envisioned by the Lancet Commission on Investing in Health.2 A Framework Convention on Global Health could chart the path towards true global health convergence, both among countries and within them, demanding the full gamut of actions to close domestic and international health inequalities that leave poorer and marginalised populations dying earlier than the well-off.
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
2207
Correspondence
For more on the platform see www.globalhealthtreaty.org
The treaty would set standards and targets, establish processes to monitor progress, and ensure accountability needed to implement the right to health. Measures could range from a domestic and international financing framework sufficient to ensure universal, affordable, and accessible health-care and public health services, through to regulations on nutrition, food marketing, and subsidies. It would assure civil society participation in developing and monitoring health policies. A treaty could facilitate right to health impact assessments, human rights education, capacity building, and national strategies on universality, comprehensiveness, equality, and accountability, with stipulations on health systems that treat all people equally, regardless of income or status. In all these ways, a Framework Convention on Global Health would help usher in an era where every individual on the planet fully benefits from global health advances. Therefore in April, 2014, we launched the platform for a Framework Convention on Global Health,3 aimed at such a treaty.4,5 The platform encompasses global and regional coordination and inclusive national platforms for all who see promise in the Framework. As a first step, we call for next year’s UN Sustainable Development Goals declaration to initiate a process towards a Framework Convention on Global Health. The Framework is surely ambitious, and many will insist that it is politically infeasible. However, the persistence of massive health inequity demands bold new strategies, which broad social mobilisation could achieve. We declare no competing interests.
*Eric A Friedman, K Srinath Reddy, Juliana Nantaba, Geetanjali Misra, Armando De Negri Filho, on behalf of the interim Steering Committee of the Platform for a Framework Convention on Global Health [email protected]
2208
Georgetown University Law Center, Washington, DC 20001, USA (EAF); Public Health Foundation of India, New Delhi, India (KSR); Center for Health, Human Rights and Development, Kampala, Uganda (JN); CREA, New Delhi, India (GM); and World Social Forum on Health and Social Security, Porto Alegre, Brazil (ADNF) 1
2
3
4
5
Ottersen OP, Dasgupta J, Blouin C, et al. The political origins of health inequity: prospects for change. Lancet 2014; 383: 630–67. Jamison T, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898–955. Anon. Platform for a Framework Convention on Global Health: realizing the universal right to health. May 14, 2014. http://www. globalhealthtreaty.org/docs/platform-for-anfcgh-full.pdf (accessed June 13, 2014). Gostin LO, Friedman EA, Buse K, et al. Towards a Framework Convention on Global Health. Bull World Health Organ 2013; 91: 790–93. Sidibé M, Buse K. A framework convention on global health: a catalyst for justice. Bull World Health Organ 2012; 90: 870–70A.
Public health or political health? On May 5, 2014, WHO issued a strong recommendation1 that all residents and long-term visitors from Pakistan, Cameroon, and Syria be immunised against polio from 4 weeks to 1 year before travel and that this be validated with an International Cer tificate of Vaccination or Prophylaxis. Recently, Paul Rutter and Liam Donaldson2 praised WHO’s decision and added: “WHO’s new recommendation on polio should not be controversial; nor should it be seen as some political sanction.” But it is most certainly political. WHO states that they considered countries that had recently exported polio, but then have not included other countries because they “would have had difficulty appearing to stigmatise countries whose number of polio cases has declined substantially, as has been the case in Nigeria and Afghanistan”. 2 If that is not political then what is—especially given the number of exportations of polio cases from Nigeria alone? The recommendation will also provide a reason for countries to limit travellers from Pakistan, Cameroon, and Syria. Before the WHO
announcement, India had mandated that any Indian citizen travelling from a polio affected country needed to have this documentation (non-Indian citizens are exempt),3 a decision now supported by WHO. This new WHO recommendation1 is likely to have minimal effects on preventing the spread of polio for a number of reasons: much crossborder traffic between listed countries (such as between Pakistan and India) is undocumented—International Certificates have no meaning for those illegally crossing the borders; certificates will need to be checked on entry, because qualified staff are not in-place; and a cottage industry of selling fake documents is likely to develop. Pakistan has done a good job of immunising its citizens and controlling the spread of polio, especially given the political situation, and should not be punished because of factors over which it has limited control. The refusal of tribal groups in Waziristan to participate in immunisation campaigns and the opposition of the Taliban, both of which have led to the killing of more than 20 vaccinators and security personnel, have placed understandable limits on Pakistan’s programme. It is time for the public health community to move beyond country borders in the overall control of infectious diseases. I declare no competing interests.
Richard A Cash [email protected] Department of Global Health and Population, Harvard School of Public Health, Boston, MA 02155, USA 1
2
3
WHO. WHO statement on the meeting of the International Health Regulations Emergency Committee concerning the international spread of wild poliovirus. http://who.int/ mediacentre/news/statements/2014/ polio-20140505/en/ (accessed June 10, 2014). Rutter PD, Donaldson LJ. Mandatory polio vaccination for travellers: protecting global public health. Lancet 2014; 383: 1695–97. Quam M, Massad E, Wilder-Smith A. Effects of India’s new polio policy on travellers. Lancet 2014; 383: 1632.
www.thelancet.com Vol 383 June 28, 2014
The Lancet—University of Oslo Commission on Global Governance for Health (Feb 15, p 630)1 articulates the various global non-health sector influences on health—namely, the global political determinants of health. The recognition of these effects is not new, but articulating a compelling way to refer to them is a useful contribution and will help to shape the future research agenda. The Commission highlights the way in which some actors are able to exert disproportionate levels of influence to serve their interests. We commend the Commission for identifying these serious power disparities in global governance, and illustrating their profound implications for health. The Commission has provoked attention to these political realities and created an important discussion. Yet the Commission’s recommendations, as the companion Youth Commission2 noted, “are likely to be influenced by the same diverging interests and power asymmetries described by the Commission”. We would like to propose a possible path forward. To tackle the global political determinants of health, there is first a need for more rigorous analysis of how national, international, and institutional actors shape and influence the global political determinants of health. The Commission refers to power, but it does not consider the need to better understand empirically how power is expressed in global health governance. The fields of international relations, sociology, and philosophy, however, do apply power as a conceptual lens for understanding how actors behave. While global health scholars led by Gill Walt3 have explored how power is expressed and exercised, power could be particularly useful to understand the global political determinants of health. www.thelancet.com Vol 383 June 28, 2014
There are a number of analytical frames to better understand or investigate power. Robert Dahl 4 proposed power as decision making (ie, A forcing B to do A’s choice against B’s will). Peter Bachrach and Morton Baratz5 argued for the importance of non-decision making (A confines B’s spectrum of possible choices); this has also been called the mobilisation of bias. Steven Lukes6 considered power as thought control (ie, A makes B want A’s choice). Together these three approaches to assess power, be it overt, covert, or latent, present one possible framework. Michael Barnett and Raymond Duvall7 presented another frame based on four approaches to power—namely, compulsory, institutional, structural, and productive forms. These frameworks, or a mix of them, could be a useful place to begin. A greater and more explicit focus on power as a tool for analysis of global political determinants of health can help to illuminate how actors create and exploit disparities to serve their interests. Crucially, a better understanding of power, which is especially important with the rise of non-health and non-state bodies’ influence over the global policy environment within which health systems must navigate, will allow for the design of policies and processes to redress disparities. We declare no competing interests.
*Robert Marten, Johanna Hanefeld, Richard Smith [email protected] The Rockefeller Foundation, New York, NY 10018, USA (RM); and Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK (RM, JH, RS) 1
2
3 4
Ottersen OP, Dasgupta J, Blouin C, et al. The political origins of health inequity: prospects for change. Lancet 2014; 383: 630–67. Gopinathan U, Cuadrado C, Watts N, et al. The political origins of health inequity: the perspective of the Youth Commission on Global Governance for Health. Lancet 2014; 383: e12–e13. Walt G. Health policy: an introduction to process and power. London: Zed Books, 1994. Dahl R. The concept of power. Behav Sci 1957; 2: 201–15.
5 6 7
Bachrach P, Baratz M. Two faces of power. Am Pol Sci Rev 1962; 56: 947–52. Lukes S. Power: a radical view, 2nd edn. Houndmills: Palgrave MacMillan, 2005. Barnett M, Duvall R. Power in global governance. Cambridge: Cambridge University Press, 2005.
The University of Oslo
Commission on Global Governance for Health: what about power?
A platform for a Framework Convention on Global Health The right to health provides the foundation to accelerate recent global health gains, extend them to the most excluded populations, and fortify them against threats beyond the health sector. Yet states often fail to meet their obligations. And the national focus can diminish effectiveness because solutions require global cooperation, from shared financing and capacity building to global norms and accountability.1 An innovative global health treaty—a Framework Convention on Global Health—could establish a right to health for the 21st century. The binding power of law would enhance the ability of civil society advocates to hold governments accountable through courts, parliaments, and the media, while creative incentives and sanctions would encourage compliance. Through international law, the Framework Convention on Global Health would ensure respect for the right to health within other legal regimes, such as trade, investment, and intellectual property—aspects of which might otherwise undermine this right. A treaty could establish the legal framework to achieve the grand convergence in global health envisioned by the Lancet Commission on Investing in Health.2 A Framework Convention on Global Health could chart the path towards true global health convergence, both among countries and within them, demanding the full gamut of actions to close domestic and international health inequalities that leave poorer and marginalised populations dying earlier than the well-off.
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
2207
Correspondence
For more on the platform see www.globalhealthtreaty.org
The treaty would set standards and targets, establish processes to monitor progress, and ensure accountability needed to implement the right to health. Measures could range from a domestic and international financing framework sufficient to ensure universal, affordable, and accessible health-care and public health services, through to regulations on nutrition, food marketing, and subsidies. It would assure civil society participation in developing and monitoring health policies. A treaty could facilitate right to health impact assessments, human rights education, capacity building, and national strategies on universality, comprehensiveness, equality, and accountability, with stipulations on health systems that treat all people equally, regardless of income or status. In all these ways, a Framework Convention on Global Health would help usher in an era where every individual on the planet fully benefits from global health advances. Therefore in April, 2014, we launched the platform for a Framework Convention on Global Health,3 aimed at such a treaty.4,5 The platform encompasses global and regional coordination and inclusive national platforms for all who see promise in the Framework. As a first step, we call for next year’s UN Sustainable Development Goals declaration to initiate a process towards a Framework Convention on Global Health. The Framework is surely ambitious, and many will insist that it is politically infeasible. However, the persistence of massive health inequity demands bold new strategies, which broad social mobilisation could achieve. We declare no competing interests.
*Eric A Friedman, K Srinath Reddy, Juliana Nantaba, Geetanjali Misra, Armando De Negri Filho, on behalf of the interim Steering Committee of the Platform for a Framework Convention on Global Health [email protected]
2208
Georgetown University Law Center, Washington, DC 20001, USA (EAF); Public Health Foundation of India, New Delhi, India (KSR); Center for Health, Human Rights and Development, Kampala, Uganda (JN); CREA, New Delhi, India (GM); and World Social Forum on Health and Social Security, Porto Alegre, Brazil (ADNF) 1
2
3
4
5
Ottersen OP, Dasgupta J, Blouin C, et al. The political origins of health inequity: prospects for change. Lancet 2014; 383: 630–67. Jamison T, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898–955. Anon. Platform for a Framework Convention on Global Health: realizing the universal right to health. May 14, 2014. http://www. globalhealthtreaty.org/docs/platform-for-anfcgh-full.pdf (accessed June 13, 2014). Gostin LO, Friedman EA, Buse K, et al. Towards a Framework Convention on Global Health. Bull World Health Organ 2013; 91: 790–93. Sidibé M, Buse K. A framework convention on global health: a catalyst for justice. Bull World Health Organ 2012; 90: 870–70A.
Public health or political health? On May 5, 2014, WHO issued a strong recommendation1 that all residents and long-term visitors from Pakistan, Cameroon, and Syria be immunised against polio from 4 weeks to 1 year before travel and that this be validated with an International Cer tificate of Vaccination or Prophylaxis. Recently, Paul Rutter and Liam Donaldson2 praised WHO’s decision and added: “WHO’s new recommendation on polio should not be controversial; nor should it be seen as some political sanction.” But it is most certainly political. WHO states that they considered countries that had recently exported polio, but then have not included other countries because they “would have had difficulty appearing to stigmatise countries whose number of polio cases has declined substantially, as has been the case in Nigeria and Afghanistan”. 2 If that is not political then what is—especially given the number of exportations of polio cases from Nigeria alone? The recommendation will also provide a reason for countries to limit travellers from Pakistan, Cameroon, and Syria. Before the WHO
announcement, India had mandated that any Indian citizen travelling from a polio affected country needed to have this documentation (non-Indian citizens are exempt),3 a decision now supported by WHO. This new WHO recommendation1 is likely to have minimal effects on preventing the spread of polio for a number of reasons: much crossborder traffic between listed countries (such as between Pakistan and India) is undocumented—International Certificates have no meaning for those illegally crossing the borders; certificates will need to be checked on entry, because qualified staff are not in-place; and a cottage industry of selling fake documents is likely to develop. Pakistan has done a good job of immunising its citizens and controlling the spread of polio, especially given the political situation, and should not be punished because of factors over which it has limited control. The refusal of tribal groups in Waziristan to participate in immunisation campaigns and the opposition of the Taliban, both of which have led to the killing of more than 20 vaccinators and security personnel, have placed understandable limits on Pakistan’s programme. It is time for the public health community to move beyond country borders in the overall control of infectious diseases. I declare no competing interests.
Richard A Cash [email protected] Department of Global Health and Population, Harvard School of Public Health, Boston, MA 02155, USA 1
2
3
WHO. WHO statement on the meeting of the International Health Regulations Emergency Committee concerning the international spread of wild poliovirus. http://who.int/ mediacentre/news/statements/2014/ polio-20140505/en/ (accessed June 10, 2014). Rutter PD, Donaldson LJ. Mandatory polio vaccination for travellers: protecting global public health. Lancet 2014; 383: 1695–97. Quam M, Massad E, Wilder-Smith A. Effects of India’s new polio policy on travellers. Lancet 2014; 383: 1632.
www.thelancet.com Vol 383 June 28, 2014
